Healthy Living Survey
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1. Home Data
1
. How old is your home?
How old is your home?
0 to 5 years
5 to 10 years
10 to 25 years
25 to 50 years
More than 50 years
2
. What style best describes your home?
What style best describes your home?
Ranch
Raised Ranch
Split level
Colonial Two Story
Cape Cod
Contemporary
Other
3
. Do you have a basement?
Do you have a basement?
Yes
No
4
. Do you have an integral garage?
Do you have an integral garage?
Yes
No
5
. The foundation of my home is:
The foundation of my home is:
Block
Sandstone
Poured Concrete
Other
6
. Does your home have a finished basement?
Does your home have a finished basement?
Yes
No
7
. How much time do you spend in your home?
How much time do you spend in your home?
4 to 6 hours per day
6 to 8 hours per day
8 to 12 hours per day
12 hours or more
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