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Free Air Purifier Survey

Name:
Do you own or rent where you live?
What is your address?
Phone:
How would you rate the air quality where you live on a scale of 1 to 10, with 1 being the worst and 10 being the best?
1
2
3
4
5
6
7
8
9
10
Do you feel as though the air quality in your home has gotten better, worse or stayed the same?
Do you or anyone in the home suffer from the following respiratory ailments? (Please select all that apply.)
Allergies
Asthma
Chronic obstructive pulmonary disease (COPD)
Emphysema
On Oxygen
Smokers
Snoring
Sleep Apnea
Do you have pets in the home that may shed?
Yes
No
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