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ABN :
   56 132 769 174

Address :
   Wesley Place,
   Rouse hill, NSW 2155
 
   P.O. Box 6872
   Norwest Business Park,
   Baulkham hills,
   NSW 2153, Australia.

Tel :
   +61-2-9836-4477
 
Fax :
   +61-2-8883-2576

Email :
   
info@khartinternational.com

 

 


DUST MITE ELIMINATOR QUESTIONNAIRES: Online Form


Instructions

  1. The questionnaire form is for the customers who uses our Dust mite Eliminator Products
  2. The online questionnaire form consists of two sections and Section 01 should be filled before using the Dust mite Eliminator Products.
  3. Section 02 should be filled after two weeks of using Dust Mite Eliminator.
 Section 01 : Pre Usage Questionnaire  

This section attempts to evaluate the conditions before using the Dust Mite Eliminator products.
 

  Email *    
 
Age *
:
 
 
Gender
:
Male  Female
 
 
State  *
:
 
 
Suburb  *
:
 
 
Do you Smoke?
:
Yes  No
 
 
Do you snore?
:
Yes  No
 
 
Do you have Dermatitis/Eczema/Skin rashes?
:
Yes  No
 
 
Do you have itchy eyes/watery eyes?
:
Yes  No
 
 
Do you have Asthma/wheezing?
:
Yes  No
 
 
Do you have blocked nose/runny nose?
:
Yes  No
 
  Do you have Family history of dust mite allergy? :
Yes  No
 
  Do you have pets? :
Yes  No
 
  Do you have Carpets in whole house/Bedrooms only? :
Whole House   Bedroom Only
 
  How frequently do you vacuum carpets? :
days/week   days/Month
 
  Do you ventilate the house frequently? :
Yes  No
 
  Do you work from home most of the time? :
Yes  No
 
  Means of transport? :
Bus   Car Rail Walk
 
  Have you had allergy testing? :
Yes  No
 
  What are you allergic to? :
dust mites grass pollen
cats dogs cockroaches
 
  Are you taking antihistamines daily? :
Yes  No
 
  Are you on Immunotherapy? :
Yes  No
 
  Do you use dust mite prevention pillow cases and bed covers? :
Yes  No
 
         

 Section 02 : Post Usage Questionnaire

 

This section attempts to evaluate the conditions before & after 14 days of Dust Mite Eliminator products usage.
First part of the section 2 is "before using Dust Mite Eliminator". This part should be filled at the same time with Section 1.
 

 
Before Using Dust Mite Eliminator After Using Using Dust Mite Eliminator
      1 2 3 4 5 1 2 3 4 5
  Sneezing /night  
  Sneezing /morning  
  Wheezing /night  
  Wheezing /morning  
  Tight chest  
  Blocked nose  
  Runny nose  
  Watery eyes  
  Skin rashes  
  Easier breathing  
  Snoring  
  Itchy skin  
 
         
 

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