The Dwell In Health Home Wellness Assessment Less than 5 minutes of your time to receive a personalized home wellness plan to create a healthier home for you and your family Name * First Name Last Name Email * Phone (###) ### #### Would you like to receive updates and tips on indoor wellness? Yes No What inspired you to take this assessment today? HOME & LOCATION DETAILS Type of home? Single-Family Apartment Townhouse/Condo Other Do you rent or own your home? Rent Own Approximate year home was built? Do you have any ongoing health conditions in the household that might be impacted by the home environment? Zip Code WATER QUALITY What is your main drinking water source? Municipal/City water Well water Filtered tap water Plastic bottled water Glass bottled water Other Water filtration systems in use? Pitcher Under-Sink Reverse Osmosis Whole-Home Filter Showerhead filter Other None Do you have water quality concerns? (select all that apply) Unusual taste or odor Visible particles or sediment Staining on fixtures Hard water buildup Fluoride Chlorine Unsure None Have you experienced any leaks in the past year? Yes No Minor only What material are your water pipes made of? Copper PEX PVC Lead Galvanized Unknown When was your water last tested? Within the last year 1-5 years ago Never Unsure AIR QUALITY What types of ventilation Systems do you have? (select all that apply) HVAC System Bathroom exhaust fans Kitchen range hood Whole-house fan Energy Recovery Ventilator Window Fans Unsure Other Do you use any HVAC enhancements at home? MERV 13+ filters UV-C Regular filter replacements Duct Cleaning Other None Do you or household members experience any of the following at home? (select all that apply) Allergies or asthma symptoms Headaches Eye irritation Throat irritation Fatigue Brain Fog Other None Do you use any of the following for moisture management? Dehumidifier Humidifier None Have you noticed condensation on windows? Yes No Have you noticed any visible mold growth in your home? Yes No Do you have any of the following at your home? (select all that apply) Gas stove Fireplace or wood stove Attached garage Newer furniture or flooring (within the last year) Pets Smokers in the household None of the above LIGHT QUALITY What types of bulbs do you primarily use? LED Smart LED CFL Incandescent Mixed Unsure For each main living area, rate natural light levels. Bedroom Very Dark (No natural sunlight) Slightly Lit by the sun Very Bright (Lots of natural sunlight) Living Room Very dark (No natural sunlight) Slightly lit by the sun Very Bright (lots of natural sunlight) Home Office/Workspace Very dark (No natural sunlight) Slightly lit by the sun Very bright (Lots of natural sunlight) Smart Lighting or Circadian Tech Used? Yes No Interested Morning Sunlight Indoors? Yes No Sometimes Sleep Issues? Falling asleep Waking groggy Fatigue Other None LIFESTYLE WELLNESS How often do you vacuum and dust your home? Daily 2-3 times per week Weekly Monthly Less frequently What types of cleaning products do you use? Conventional products Natural/eco-friendly products DIY Cleaners Mixed Other Fragrance Use? Candles Air fresheners Essential Oils Other None Pets at home? Dog/s Cat/s Other Do you cook often at home? Yes No Sometimes Average time spent at home daily >20 Hours 12-20 Hours <12 Hours Do you have children or Seniors at home? Yes No BUILDING SYSTEMS & MAINTENANCE Recent work in the last 3 years? HVAC Plumbing Roofing Remodel Other None Do you have a maintenance routine for the home? Yes No Interested Do you use any smart home monitoring devises? Yes No Interested Any other recent issues with your home? High utility bills Humidity Drafts Electrical Appliances Other None GOALS & BUDGET What are your top priorities for a healthier home? Allergy relief Indoor air quality Clean water Better sleep Energy efficency Mold prevention Lighting for circadian rhythm Help health issues Prepping for new baby Reduce chemical exposure Temperature/humidity management Other None Open to consulting support? Yes No Maybe What investment level are you comfortable with for home wellness improvements? Minor adjustments (<$500) Moderate upgrades ($500-$2000) Major improvements ($2000-$5000) Comprehensive renovations (>$5000) Prefer not to specify You’re on the way to a healthier home! Please give us 2-3 business days to prepare your personalized home wellness plan based on the answers and budget you provided. Thank you! Thank you for completing the form. Please give us 2-3 business days to create your personalized home wellness plan.
