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General Home Information

Type of Home:

Size of Home:

Years at this location:

# of Residents in Home:

Years with Chronic Illness:

How many other residents have illnesses:

Home Exterior & Landscape

Home built on high point of lot

Water Collects in yard

Wall shows water damage

Water Flows toward home

Roof and Attic

Roof Leaks

Gutters Leak

Bird Damages

Wet Insulation

Blown-In Type Insulation

Rodent Damages

Home Interior

Interior Flooding

Visible Water Stains on Ceiling

Visible Water Stains on Walls

Carpets have been wet

Buckled Hardwood Flooring

Leaking Water Pipes

Leaking Sewer Pipes

Insect Damages

Rodent Damages

Pet Damages

Basement/Crawlspace Water Problems

Foul / Moldy Odors

Stains on Ceiling

Carpets have been wet

Exposed Dirt Floor

Flooding or Mold

Leaking sewer pipes

Leaking Water Pipes

Leaking A.C. Drains

HVAC System and Air Filtration

HVAC System in Attic

HVAC System in Basement

Ductwork Cleaned in the last 6 months

HVAC filters replaced in the last 30 days

HEPA System Installed

HEPA Maintained in the last 6 months

Other Air Filtration Systems Installed

Let's Take a Look at your Health

General Health Information

Unhealthly Symptoms

Allergies	Asthma
Bronchitis	Eye Infections
Ear Infections	Eczema
Sinus Congestion	Athletes Foot
Headaches	Sleep Apnea
Respiratory Inflammation	Chronic Fatigue

Life Threatening Symptoms

Fibromayalgia	chemical Sensitivities
Infectious Deseases	AIDS
Birth Defects	Cancer
SIDS	Leukemia
Gas Poisoning	Asbestos Poisoning
Neurological Disorders	Digestive Disorders

How do we reach you?

General Contact Information

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Evening Phone:

E-Mail Address

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Questions & Comments

For more information:
Environmental Solutions
Email: info@esi4u.com
410-867-6262
Fax: 410-867-6333

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