Home EMF Environmental Assessment Questionnaire

Client Intake & Lifestyle

Focused on Electromagnetic Radiation (EMR)

This assessment will help to evaluate environmental factors that may influence sleep quality, nervous system balance, respiratory health, and overall well-being by evaluating electromagnetic radiation (EMR). Please fill out the questionnaire to the best of your ability. By answering these questions, we will be able to have a better focused more successful visit.

All information shared is confidential and used solely to personalize your assessment.

1. Client Information

2. What Inspired You to Schedule This Assessment?

3. Sleep & Wellness Experience

Have you or anyone in the home experienced:Check all that apply.
Do you feel better when away from home (vacation, outdoors, etc.)?

4. Property Description

Type of Residence
Basement
Crawlspace
Primary Construction Type
Do you have a pool?
Hot Tub?
Have there been any renovations in the last few years?

5. Outdoor Environmental Factors

Nearby: Check all that apply.

6. Your Home’s Electrical & Wireless Environment

Smart meter installed?
Solar panels?
Electric vehicle charger?
Utility service
Wireless & EMF Sources – please check all that are present in the home
Do you carry you phone in your pocket?

7. Sleep Space (Priority Area)

Is the bed against an exterior wall?
Is a smart meter located near that wall?
Are electronics within 6 feet of the bed?
Is Wi-Fi left on overnight?
Do you charge your phone overnight near the bed?
Do you sleep with your phone on your nightstand or near the bed?
Do you have a TV in your bedroom?
If so, it is a Smart TV?
Do you have an electronic adjustable bed?
Do you have a metal frame?
Do you have any other electronics in your bedroom?
Additional bedrooms and occupantsPlease note if any of the other bedrooms have any of these concerns mentioned above.
What direction is the head of your bed?
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4

8. Home Office

Do you have a home office?

9. Lighting

What type of lighting is used in your home?Check all that apply.

10. Your Wellness Goals

What would feel like a successful outcome for you?Check all that apply.

11. Scope of Services, Limitations & Liability Disclosure

The EMF Environmental Assessment is a non-invasive, limited-scope evaluation of electromagnetic radiation (including electric fields, magnetic fields, radiofrequency, and dirty electricity) and observable indoor air quality conditions at the time of inspection. The assessment is conducted in accordance with generally accepted building science principles and may reference guidelines developed by the International Institute for Building Biology & Ecology. This evaluation is not an electrical code compliance inspection, engineering analysis, or medical diagnosis. Findings reflect conditions present only at the time of the site visit and may vary due to weather, utility load, occupant activity, seasonal changes, or external sources beyond the assessor’s control. Concealed or inaccessible areas are not evaluated. No guarantee or warranty of future environmental conditions or health outcomes is expressed or implied. By signing below, the client acknowledges understanding and acceptance of this scope and its limitations.