Symptom Questionnaire Customer Name:* Customer Phone #:* Customer Email: Vehicle (year, make, model): Vehicle Symptoms/ Description:* When did this problem first start to happen? Has this vehicle ever been looked at/worked on for this problem before? (if Yes, What work was done, and did it make any difference?) Yes No Does the vehicle have a problem if the weather conditions are Cold onlyHot onlyHot or cold onlywet onlyDrt onlyNo difference Have there been any changes in: Acceleration Yes No Gas mileage Yes No Engine Performance Yes No Fluid levels Yes No Handling Yes No Braking Yes No Steering Yes No Vibrations Yes No Other (describe): Does the vehicle have a problem when the engine is: Cold only? YesNoThird Choice Warm only? YesNo Warm or cold? Yes No Other Have you noticed any unusual: Sounds YesNo Drips YesNo Smoke YesNo Gauge Reading YesNo Odors YesNo Leaks YesNo Warning Lights YesNo Other (describe): Approximately how ofter does this problem occur: Every time vihecle is drivenOnce a weekonce a day Other (describe): What has been the longest period of time, during which you did not notice the problem: 1 Hour2 Hours3 Hours6 Hours1/2 Day1 Day1 week Other (describe): Has the vehicle been sitting or stored for any length of time? If so, how long? Is the vehicle normally garaged? YesNo Has the vehicle ever been in an accident? YesNo Is the vehicle only driven on short trips? YesNo (if Yes, what was damaged?) Has the vehicle been stolen/recovered recently? YesNo Has the vehicle just been washed? YesNo Have you ever noticed wet carpeting? YesNo Has the vehicle ever been in a flood? YesNo Does the vehicle have a salvage title? YesNo Has the vehicle recently had any body work Or other repairs? YesNo Has a stereo or other accessory recently been Installed? YesNo Does the vehicle’s radio have static? YesNo Are there any electrical accessories that do not work? YesNo Have you ever noticed any electrical issues? YesNo (If yes, please list): (If yes, please list): Did the problem happen shortly after gas purchase? YesNo Any recent change of gas brands? YesNo Any unusual gas smells? YesNo Did the problem occur right after loaning the car to someone else? YesNo Does altitude seem to have any effect? YesNo Does the number of occupants/passengers have any effect? YesNo Does the temperature gauge ever show overheat? YesNo Does the temperature gauge ever show very low temperature? YesNo Is the vehicle equipped with an anti-theft device? YesNo Does the heater take a long time to put out hot air? YesNo Does the vehicle have a hidden “Kill” switch? YesNo If yes, does it work? YesNo Any other information that you feel might be useful? Thank you for taking the time to review this form and fill it out. Accurate information is a valuable tool for your technician and will assist in making an accurate and timely diagnosis.