CUSTOMER PHONE#:
CUSTOMER EMAIL:
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?)
HAVE THERE BEEN ANY CHANGES IN:
Acceleration
Engine Performance
Gas mileage
Fluid levels
Handling
Braking
Steering
Vibrations
DOES THE VEHICLE HAVE A PROBLEM IF THE WEATHER CONDITIONS ARE:
Other
DOES THE VEHICLE HAVE A PROBLEM WHEN THE ENGINE IS:
(warm – normal operating temperature)
VEHICLE (year, make, model):
VEHICLE
SYMPTOMS/
DESCRIPTION:
WHEN DID THIS PROBLEM FIRST START TO HAPPEN?
Cold only?
Warm only?
Warm or cold?
Other (describe):
HAVE YOU NOTICED ANY UNUSUAL:
Sounds
Drips
Leaks
Smoke
Warning
Lights
Gauge
Reading
Odors
Other (describe):
Has the vehicle been sitting or stored for any length of time? If so, how long?
Is the vehicle only driven on short trips?
Has the vehicle ever been in an accident?
(if Yes, what was damaged?)
Has the vehicle been stolen/recovered recently?
Has the vehicle just been washed?
Have you ever noticed wet carpeting?
Has the vehicle ever been in a flood?
Does the vehicle have a salvage title?
Has the vehicle recently had any body work Or other repairs?
Has a stereo or other accessory recently been Installed?
Are there any electrical accessories that do not work?
APPROXIMATELY HOW OFTEN DOES THIS PROBLEM OCCUR:
Other (describe):
WHAT HAS BEEN THE LONGEST PERIOD OF TIME, DURING WHICH YOU DID NOT NOTICE THE PROBLEM:
Other (describe):
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.
Any other information that you feel might be useful?
Is the vehicle normally garaged?
Does the vehicle’s radio have static?
(If yes, please list):
Have you ever noticed any electrical issues?
(If yes, please list):
Did the problem happen shortly after gas purchase?
Any recent change of gas brands?
Any unusual gas smells?
Did the problem occur right after loaning the car to someone else?
Does altitude seem to have any effect?
Does the number of occupants/passengers have any effect?
Does the temperature gauge ever show overheat?
Does the temperature gauge ever show very low temperature?
If yes, even after driving 20-30 minutes:
Does the heater take a long time to put out hot air?
Is the vehicle equipped with an anti-theft device?
If yes, does it work?
Does the vehicle have a hidden “Kill” switch?
CUSTOMER NAME:
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Prior to your Appointment, just fill this form in and hit "Submit". It will be emailed directly to Amtech.
INTERMITTENT SYMPTOM QUESTIONNAIRE
8202 S. 48th Street
Bellevue, NE 68157
(402)734-2865
Hours: 8:00 a.m. to 5:30 p.m. Monday - Friday
