Home Water Risk Assessment

Your Symptoms

*Check All That Apply

Which of these symptoms
do you experience?

Fatigue or low energy Brain fog Digestive problems Skin rashes or irritation Reoccurring Illnesses Recurring infections Headaches Sleep problems Inflammation Respiratory & sinus issues Anxiety Eyes, nose & throat irritation

Symptom Patterns

*Check All That Apply

Have you noticed any
of these patterns?

Symptoms improve when drinking primarily bottled or filtered water Skin, hair, or sinus symptoms flare up after showers or baths More than one household member has similar unexplained symptoms Symptoms began or worsened after moving to this home You feel better when traveling or away from home You notice a taste or smell in your tap water Pets hesitate to drink the tap water, or have unexplained health issues None of these currently apply to me

Steps You've Taken

*Check All That Apply

What steps have you
already tried?

Consulted multiple doctors Tested your water quality before Installed a water filter or pitcher filter Switched to bottled water for drinking Tried medications Had blood tests Installed a water softener Changed your diet or tried supplements

Your Water Source

*Check All That Apply

Where does your
home's water come from?

Private well on the property A mix of well and municipal water Not sure where your water comes from City or municipal water supply Rent or recently moved, with no water history information Whole-home or under-sink filtration already in place

Water Warning Signs

*Check All That Apply

Have you noticed any of these
in your home's water?

Discolored water (yellow, brown, or rusty at times) Rotten egg or sulfur smell Musty or earthy taste or smell Metallic taste Sediment or particles in the water Rust, blue-green, or dark staining on fixtures, tubs, or laundry Cloudy or milky appearance Strong chlorine or chemical smell Heavy scale buildup on faucets, kettles, or appliances None of these apply to my water

Plumbing & Infrastructure

*Check All That Apply

Which of these apply to your
home's plumbing and water system?

Home built before 1986 (lead solder and galvanized pipe era) Well has never been professionally inspected or serviced Plumbing has never been updated, or you're not sure if it has Older neighborhood with aging municipal water infrastructure Past leaks, corrosion, or water damage under sinks or around fixtures Water heater is more than 10 years old Water softener or filtration system not serviced in over a year Frequent pressure changes, banging pipes, or plumbing repairs

Your Health Journey

*Check All That Apply

Which of these describe
your health experience?

Seen 2 or more doctors or specialists Symptoms are getting worse over time No clear diagnosis despite testing Medications haven't fully resolved symptoms Symptoms have lasted 6 months or more Been told symptoms may be stress or anxiety Ongoing digestive or gut issues despite diet changes Tried alternative or functional medicine

Your Household

*Check All That Apply

Which of these describe
your household situation?

Others in my home share similar health symptoms Someone in my home has a chronic illness or compromised immune system Babies, young children, or elderly family members in the home I am the only one experiencing ongoing health symptoms My pet(s) have unexplained health issues

Property Surroundings

*Check All That Apply

Which of these describe
the area around your home?

Near farmland, orchards, or areas with fertilizer and pesticide use Near industrial facilities, factories, or manufacturing plants Near a landfill, dump site, or gas station Located in a flood-prone or high water table area Septic systems on or near the property Heavy winter road salting near your well or water source Rural or suburban area with none of these nearby

Previous Testing

*Check All That Apply

Has your home's water
ever been tested?

The water has never been tested for contaminants Test results came back fine, but symptoms have continued Only tested for bacteria, not metals, chemicals, or mold and fungal toxins Only tested for hardness, taste, or odor issues Rely on the annual city water report Installed filtration without testing what was in the water first Received test results but wasn't sure what they meant I have had a comprehensive water test for mold, metals, chemicals, bacteria and more, and it identified what the problems were and why

Almost There

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send your results?

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Which of these symptomsdo you experience?

Have you noticed anyof these patterns?

What steps have youalready tried?

Where does yourhome's water come from?

Have you noticed any of thesein your home's water?

Which of these apply to yourhome's plumbing and water system?

Which of these describeyour health experience?

Which of these describeyour household situation?

Which of these describethe area around your home?

Has your home's waterever been tested?

Where should wesend your results?

Your Home WaterRisk Assessment Results

Which of these symptoms
do you experience?

Have you noticed any
of these patterns?

What steps have you
already tried?

Where does your
home's water come from?

Have you noticed any of these
in your home's water?

Which of these apply to your
home's plumbing and water system?

Which of these describe
your health experience?

Which of these describe
your household situation?

Which of these describe
the area around your home?

Has your home's water
ever been tested?

Where should we
send your results?

Your Home Water
Risk Assessment Results