Feel free to copy and modify according to your own needs.
If there’s an interested and cooperative vendor or real estate agent who can speak with the vendor (or property manager, etc) to get the answers to as many of these questions as you need answered for your health, it’s easier to make better decisions about being able to function in a potential new home.
You can also use the list in other ways. Feel free to use as needed.
QUESTIONS regarding potential health issues for interested buyer /renter who suffers from severe allergies and chemical sensitivities.
We need and appreciate your complete honesty when answering these questions, realizing they may seem unusual. There are no right or wrong answers.
Your answers will help us to understand what substances and materials have been and may still be present in this environment, and if these are ones that are safe, or are present in safe amounts for the prospective buyer to be exposed to. Sometimes trace amounts are dangerous, so we need to know the history. What may be normal and cause no problems for most of us may cause symptoms ranging from mild and irritating, to severe neurological effects, or something similar to what you might expect from someone with a peanut allergy.
We realize that no place will be perfect. The goal is to find a home that is least likely to have an impact on the existing medical condition. We expect that some remediation or modification may need to be done before moving in to any home, and need to know to what extent this may or may not be possible here.
Thank you for your co-operation.
Phone Number: _____________________________ Daytime Number:______________________
Email: _____________________________________ Other _______________________________
Please answer the following to the best of your knowledge. If you are not sure of an answer, please indicate that you “don’t know”.
1) What is the approx. age of your home? _____ years
2) What direction does your house face? Circle two, if applicable: N E S W
3) What direction are your prevailing winds from? Circle two, if applicable: N E S W
4) Have you ever used Any plug-in type air fresheners ? Y ___ N ___
IF YES… thank you but we cannot proceed.
If yes to any of these, approximately how often, where, and how long ago did you use them last?
All these products tend to be absorbed into walls, cabinetry etc, and contain substances which cannot be easily removed.
Any other air fresheners? Y ___ N __ _________________________________________
Sprays like Lysol? Y __ N __ _________________________________________
Scented candles? Y __ N __ _________________________________________
Incense? Y __ N __ _________________________________________
5) Do you use fabric softeners for the laundry? Yes____ No_____
Do you recall ever having spilled fabric softener on the floor before? Y___ N ___
If yes, where, on what kind of a surface, and approximately how long ago did this happen?
6) Have you used WD40 or other lubricant in the home before? Y ___ N ___
If yes, please specify where and when used: _______________________________________
7) What products do you use to clean the following areas? When were they last used?
a) kitchen ___________________________________________________________________
b) bathroom ___________________________________________________________________
c) carpets/floors ___________________________________________________________________
d) permanent wood fixtures ___________________________________________________________________
e) wood floors ___________________________________________________________________
f) appliances ___________________________________________________________________
8) Is there anywhere else you use another cleaning product? If so, where, and what do you use?
9) Are any scents, cleaning or deodorizer products used in the closets/cabinets? Y___ N ____
If yes, please indicate where and what is used: _____________________________________
10) When was the most recent painting done and where? ________________________________
11) Have you conducted any recent (within 10 years) renovations on this property? Y ___ N ___
Of particular interest are any recent interior counters or cabinet installations (using particle board, MDF, or plywood), caulking or gluing, windows, flooring (vinyl, laminate, hardwood, tile…), carpet installation, roofing, plumbing or water damage repairs, or mould remediation work.
If so, please indicate what, where, and when these were done:
12) Have you ever used pesticides (for insects and rodents) in the home before? Y ___ N ___
If yes, please indicate what you used, where was it used, and when:
a) Store bought spray pesticides (such as Raid) _______________ (please name product used)
Used approx. _____ days/months/years ago in __________
b) Professional pest control spraying ___
Used approx. _____ days/months/years ago in ______________
c) Ant traps ___ d) Glue Paper ___
e) Other (please specify): ____________________________________
Used approx. _____ days/months/years ago where __________
13) What is your water source? __________________________________
If you have well water, how often is it checked? ___________________
Is anything required to make your well water safe to drink? __________
14) Does this home use a septic system? Y N
If yes, when was the system last fully maintenanced? _________________________________
When is the system due to be maintenanced again? __________________________________
15) Please indicate any odours, however small, that you may recall sensing either in your home or outside over the past year:
a) Neighbour’s BBQ ___ Detected inside ____ outside _____
b) Wood smoke from fireplaces ___ Detected inside ____ outside _____
c) Woodburning stoves ___ Detected inside ____ outside _____
d) Gas fumes (or propane, or oil) ___ Detected inside ____ outside _____
e) Neighbour’s laundry line or dryer exhaust ___ Detected inside ____ outside _____
f) Roofing tar or asphalt ___ Detected inside ____ outside _____
g) Garbage dump ___ Detected inside ____ outside _____
h) Burning garbage ___ Detected inside ____ outside _____
i) Diesel /propane exhaust fumes ___ Detected inside ____ outside _____
j) Industrial smells (if so, please specify if known): ____________________________________
16) Are there any go cart, ATV, or snowmobile trails nearby? Y N Don’t know ___
If yes, approximately how far away are these trails from your residence? __________________
17) Do you know of any planned roadwork near your home? Y N
18) When was your road last resurfaced? ___________________________ Don’t know ______
19) Do you often see or hear airplanes near your residence? Y N
20) Approximately how far away is the nearest airport from your home? ______________________
21) Are there any industries or factories operating close to where you live? Y N Don’t know___
If yes, approximately how far are they from your home? If you can, please also specify what is produced.
22) Are any of the following businesses located within 1 mile of your home:
a) Laundromats? Y ___ N ___ Don’t know ___ If yes, approx. distance from home: __________ Direction ___________
b) Dry cleaners? Y ___ N ___ Don’t know ___ If yes, approx. distance from home: __________ Direction____________
c) Hair salons? Y ___ N ___ Don’t know ___ If yes, approx. distance from home: __________ Direction___________
d) Other (please provide details): _______________________________________________________________________
23) Do you know of any cell phone towers located within 2 miles of your home?
Y ___ N ___ Don’t know ___
24) Do you know of any future plans to erect cell phone towers nearby?
Y ___ N ___ Don’t know ___
25) Are there any high transmission power lines located within 2 miles of your home?
Y ___ N ___ Don’t know ___
26) Is there a golf course located nearby? Y N
If yes, approximately how far and in which direction? ____________direction_____________
27) How close are the nearest rail lines to your home? __________________________________
28) Is there a farm located nearby? Y ____ N ______ Several ________
If yes, approximately how far is it/are they from your home? ____________ directions _______
If you can, please specify what is farmed and in what direction :
29) Do you know of any outdoor pesticide or fertilizer use by you or your neighbours or township?
Y ___ N ___ Don’t know ___
If yes, please specify where used: and products used
This residence ___
DIY ___ Hired company ___ Frequency of use: __________ Products_______________________
By neighbours ___
DIY ___ Hired company ___ Frequency of use: __________ Products ______________________
Township ___ Utilities ____ How often and where _______________________________________
30) How would you describe the traffic on your road? Rare ___ Regular ___ Busy ____
Approximately __________ cars/hour at peak times
31) Is your driveway currently plowed by a service? Y ___ N ___ Reccomend? ___________
How long is the driveway? __________ How far is the house from the road? ______________
32) Do you have outdoor laundry lines? Y ___ N ___ If no, can lines be installed? Y ___ N___
33) Is there a Vegetable garden here? Y ___ N ___ Flower garden? Y ___ N ___
34) What kinds of flowering trees are located on the property?
a) None ___ d) Jasmine ___
b) Catalpa ___ Other ______________________________
c) Lilac ___ Other ______________________________
35) Please indicate, to the best of your knowledge, your closest neighbours and their approximate distance from your property. Where there are no neighbours, please indicate the type of land in the specified direction (e.g. conservation land, swamp, horse farm, etc.)
a) North: _________________________________Approx. distance from property: __________
b) East: __________________________________Approx. distance from property: __________
c) South: _________________________________Approx. distance from property: __________
d) West:__________________________________Approx. distance from property: __________
36) What type of heating system does your home have? __________________________________
37) Do you have forced air vents? Yes ___ No _____
If yes, are they lined? Yes ___ No _____
Have they been recently cleaned? Yes ___ No _____
If yes, by whom? ____________________________ When? __________
Were sprays/anti-bacterials used in the cleaning process? Yes ___ No ___ Don’t Know ___
38) Please indicate if your home contains any of the following:
a) Air exchange unit? _____________ Last serviced: __________
b) HRV _____ with VOC filters? _____ Last serviced: __________
c) Attached Humidifier? ___ Last serviced: __________
d) Central Vac? ___ Last serviced: __________
e) Water filter or conditioner? ___ Last serviced: __________
39) If known, please indicate the material used in your plumbing pipes: ___________________
40) Do you know of any lead in your plumbing? Yes ___ No ___ Don’t Know ___
41) Is the laundry room/area enclosed? Yes___ No___ Type of door_________________ What materials are the floors made of?________ Walls?________
42) What material are the kitchen cabinets? _______________Bathroom cabinets ____________
43) Is high speed internet available here? Y ___ N ___ Don’t know ___
44) Is the mail delivered to the door? Y ___ N ___
If no, how far away do you have to travel to pick up your mail? __________________________
45) Is there a garage? Yes___ No____ Is it Heated? ___________________________________
Other out buildings? ___________________________________________________________
Gazebo or covered porch or deck? _______________________________________________
46) Is the area quiet? Yes ____ No____ Can you hear any neighbours? ____________________
What kind of sounds are regularily heard here, and are they seasonal or regular?
47) Does the house have an enclosed entryway / foyer? Yes _____ No _____
With an enclosed closet? Yes _____ No_____
48) When was the roof last replaced? _________________________________________________
Is there anything else we may have missed, good or bad, that you want to add?
Maybe some of these should be in this questionnaire also…
What materials are the bathroom cabinets/sink/counter made of?____________
Is the tub and surround plastic/acrylic or enamel and tiles________________
What materials are the floors made of – list
Is there any wood panelling?
What is the finish on it? (paint, shellac, urethane,…)
What walls are the utility meters against? (bedroom, kitchen, etc)
Is there a smart meter, and if so, against which wall/room of the house?
Those are all our questions for now. Thank you
Here’s a helpful checklist from reshelter:
Here’s a useful document download of things to be aware of when house-hunting, from MCS-CanadianSources (copied in 2008, not updated)