Water Quality Questionnaire 2019 Name *FirstLastAddressEmail *Phone NumberSpouse's NameSpouse's Phone NumberSpouse's EmailHas any member of your household experienced any of the following? Acid Reflux/ HeartburnItchy Dry SkinEczema / PsoriasisDry / Brittle HairClick all that apply to you.Has anyone noticed your water having a strange odor or smell? Chlorine / AmmoniaSulfer / Rotten EggMetalic ChemicalEarthy / MustyClick all that apply to you.Have you recently noticed any of the following regarding your tap water?DiscolorationIron StainingScale Build-UpMineral DepositsSoap Scum / FilmReplaced Water HeaterCheck all that apply to you.What water do you typically drink? Bottled Water - SinglesBottled Water - GallonsBottled Water - DeliveryAlkaline Bottled WaterReverse Osmosis WaterRefills / WindmillRefrigerated Filtered WaterPour-Thru Pitcher Filtered WaterFacet Mounted Filtered WaterTap WaterCheck all that apply to you.Have you had your water tested since moving into this home? Not yet but I would like to have it tested.We are testing it now. NoCan't recall.Check all that apply to you.What is the approximate age of your home? New Construction1-3 Years3-10 Years10-20 Years20+ Years OldWhich is your water source? City WaterCommunity Well / MUDPrivate WellNot yet connected.When is the best time to contact you? 8-10 AM10 AM - 12:00 NOONNoon - 2 PM2PM - 5 PM5 PM - 8 PMAnytimePlease select the best time.Do you have any additional questions for us? EmailSubmit By Houston Water SolutionsWater Quality QuestionnaireMay 9, 2019November 1, 2019