Environmental Chi Assessment

Sample Intake Survey

1. Assessment is for:
   ___ Home ___ Office ___ Studio ___ Other

2. Your name: ___________________________________

3. Date of birth: ___________________________________

4. Time and place of birth: ___________________________________

5. People sharing your space
   (names, DOB, relationship to you, other pertinent information)

6. Address and location of building: ___________________________________

7. Age of building: ___________________________________

8. History of building: ___________________________________

9. What surrounds the building?
   North: ___________________________________
   South: ___________________________________
   East: ___________________________________
   West: ___________________________________

10. What direction does your front door face? ___________________________________

11. Is the door to the Right, Left or Center as you look at the front of the building? ___________________________________

12. Describe your feelings about your space (sleep habits, work habits, health issues, etc.)

13. What do you like best about your space?

14. What bothers you the most about your space?

© 1999, Kari C. Tauring. All Rights Reserved.
Last revised: 10/22/1999; 1:12:50 AM