Sage Living EMF Intake Forms (Master)

Electric and Magnetic Field Overview

Exterior readings

Interior readings

Interior AC Fields

Breaker assessment

Client Information

Client Name:

Date:

Address:

Phone Home:

Phone Cel:

Email:

Referred by:

Notes / Specific Concerns:

Electrically Sensitive:

Rent home:

Own home:

Square footage:

Number of Bedrooms:

Number of Offices:

Basement:

Aluminum wiring:

Knob and tube wiring:

Siding type:

Roof type:

Year built:

Solar PV System:

RF Monitoring:

Variable Speed Metering System:

Water well:

Smart appliances:

Smart electical service:

Smart gas service:

Smart water service:

RF smoke detector system:

RF thermostat system:

RF CO₂ system:

RF security system:

RF security cameras:

RF baby monitor:

RF audio speakers:

RF voice communication system:

RF satelite system:

RF celular booster:

Things controlled by smart phones:

WiFi and / or Bluetooth in Atomobiles:

Wi-Fi Router 2.4 GHz:

Wi-Fi Router 5 GHz:

Wi-Fi Router hotspots:

Wi-Fi extenders:

ZigBee router:

Dimmer light siwtches:

CFL bulbs:

Fluorescent bulbs:

Televisions:

Televisions with Wi-Fi:

Gaming console:

Cordless phones:

AppleTV:

Roku:

AmazonFire:

ChromeCast:

Other DVB:

Printers:

Printers with Wi-Fi:

Bluetooth keyboards:

Bluetooth mice:

Bluetooth auto speakers:

Bluetooth headsets:

Smart watches:

Fitbits:

Next steps

Electric and Magnetic Field Overview

Exterior readings

Interior readings

Interior AC Fields

Breaker assessment