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?)YesNoDoes the vehicle have a problem if the weather conditions areCold onlyHot onlyHot or cold onlywet onlyDrt onlyNo differenceHave there been any changes in: AccelerationYesNoGas mileageYesNoEngine PerformanceYesNoFluid levelsYesNoHandlingYesNoBrakingYesNoSteeringYesNoVibrationsYesNoOther (describe):Does the vehicle have a problem when the engine is:Cold only?YesNoThird ChoiceWarm only?YesNoWarm or cold?YesNoOtherHave you noticed any unusual:SoundsYesNoDripsYesNoSmokeYesNoGauge ReadingYesNoOdorsYesNoLeaksYesNoWarning LightsYesNoOther (describe):Approximately how ofter does this problem occur:Every time vihecle is drivenOnce a weekonce a dayOther (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 weekOther (describe):Has the vehicle been sitting or stored for any length of time? If so, how long?Is the vehicle normally garaged?YesNoHas the vehicle ever been in an accident?YesNoIs the vehicle only driven on short trips?YesNo(if Yes, what was damaged?)Has the vehicle been stolen/recovered recently?YesNoHas the vehicle just been washed?YesNoHave you ever noticed wet carpeting?YesNoHas the vehicle ever been in a flood?YesNoDoes the vehicle have a salvage title?YesNoHas the vehicle recently had any body work Or other repairs?YesNoHas a stereo or other accessory recently been Installed?YesNoDoes the vehicle’s radio have static?YesNoAre there any electrical accessories that do not work?YesNoHave you ever noticed any electrical issues?YesNo(If yes, please list):(If yes, please list):Did the problem happen shortly after gas purchase?YesNoAny recent change of gas brands?YesNoAny unusual gas smells?YesNoDid the problem occur right after loaning the car to someone else?YesNoDoes altitude seem to have any effect?YesNoDoes the number of occupants/passengers have any effect?YesNoDoes the temperature gauge ever show overheat?YesNoDoes the temperature gauge ever show very low temperature?YesNoIs the vehicle equipped with an anti-theft device?YesNoDoes the heater take a long time to put out hot air?YesNoDoes the vehicle have a hidden “Kill” switch?YesNoIf yes, does it work?YesNoAny 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.