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FREE Energy Health Check
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Please complete this Energy health Check Questionaire, will will then get in touch with you in order to arrange an appointment to discuss your needs, with a view to saving you money.
Name:
Phone No (Mobile):
Phone No (Day Time):
Email Address:
Address:
What is your property type
Please Select
House
Flat
Bunlalow
Maisonette
What type of home do you live in
Please Select
Detached
Semi-Detached
Mid-Terrace
End-Terrace
In what year was your home built
Please Select
Before 1900
1900 1929
1930 1949
1950 1965
1966 1974
1975 1981
1982 1990
1991 1995
1996 2002
After 2002
Do you own or rent your property
Please Select
Own / Buying on mortgage
Renting privately
Renting from council
Renting from housing association
Tied house / Other
Does your home have a heated conservatory and if so are its windows double glazed
Please Select
Yes - double glazed
Yes - not double glazed
No - heated conservatory
How many rooms (bed, living and dining) do you have (Include hall, stairs and landing as one room)
Please Select
1
2
3
4
5
6
7
8
9
How many storeys does your property have (for flats and maisonettes only include your home, not the whole block)
Please Select
1
2
3
4+
Does you home have a garage built into the house
Please Select
No
Yes - single
Yes - double
Yes - other
Only If You Live In a Flat
Is your flat
Please Select
Part of converted house
Purpose buit block (up to 5 storeys)
Tower Block (6 storyes or more)
Where is your flat positioned in the building
Please Select
Basement
Ground Floor
Mid Floor
Top Floor
How many walls of your flat are fully exposed to the outside
Please Select
4 Walls
3 Walls
2 Walls
1 Wall
For All Types Of Property
What is your main wall type
Please Select
Stone
Insulated cavity
Uninsulated cavity
Timber frame
Solid brick
Other
How much loft insulation do you have
Please Select
Don't know
No access to loft
None
Up to 50mm (2")
100mm (4")
150mm (6")
200mm (8")
250mm (10")
250mm+ (10+)
How much of the property is double glazed
Please Select
None
Some (25%)
About half (50%)
Most (75%)
All (100%)
What is the double glazing rating
Please Select
Not Rated
"C" or below
"A"
If you have single glazed windows are they draft proofed
Please Select
None
Yes
No
How many open fireplaces with chimneys do you have
Please Select
None
1
2
3
4
5
6
7
8
How many of your lights have low energy light bulbs fitted
Please Select
None
Some
All
Are you thinking of buying a new electrical appliace for your home in the future
Please Select
Yes
No
What is the main heating system
Please Select
Boiler supplying radiators
Room heaters or fires
Community heating
Bottled gas (cylinders)
Warm air
Ceiling heating
Storage heaters
If The Main Heating System Is a Boiler
When was your boiler installed
Please Select
1997 or earler
During or after 1998
What type of boiler does your property have
Please Select
Normal (with hot water tank)
Condencing (with hot water tank)
Combination
Condencing combination
Back boiler
If The Main Heating System Is Storage Heaters
What type of storage heaters are there
(Please click on box for all those that apply)
Old (large volume heaters)
Modern (slim line heaters)
Convector storage heaters
Fan-assisted storage heaters
If The Main Heating System Is Room Heaters
What type of room heaters are there
(Please click on box for all those that apply)
Standard gas fire
Open fire
Electric heaters
Closed room heater / stove
Decorative gas fire in open fireplace
Open fire with back boiler (supplying hot water only)
Gas fire with back boiler (supplying hot water cylinder only)
Closed room heater with back boiler (supplying hot water only)
For All Types Of Heating System
What heating controls does your system have
(Please click on box for all those that apply)
Room thermostat (temperture control)
Programmer (time clock)
Thermostatic radiator valves (TRV's)
How is your water usually heated
Please Select
From main heating system
Back boiler
Electric immersion (off peak)
Electric immersion (on peak)
Instant electric water heating
What is the size of your hot water cylinder
Please Select
No cylinder
Don't know
No access to cylinder
Normal (up tp 90cm/36"and 135cm/54" tall)
Large (over 135cm/54" tall)
What type of hot water cylinder insulation do you have
Please Select
None
Thin jacket
Thick jacket
Solid foam
Is there a thermostat on the water cylinder
Please Select
Yes
No
Is solar hot water present
Please Select
Yes
No
Is solar PV present
Please Select
Yes
No
Recent Changes
(In this section, please select "No" if you don't know )
Have you installed any of the following in the last Twelve months
Loft insulation
Please Select
No
Yes added 50mm (2")
Yes added 100mm (4")
Yes added 150mm (6")
Yes added 200mm (8")
Cavity wall insulation
Please Select
Yes
No
Draft proofing
Please Select
Yes
No
Double glazing
Please Select
Yes
No
New boiler
Please Select
Yes
No
Hot water tank jacket
Please Select
Yes
No
The following questions will help us to tell if you may be eligible for a grant
Is a member of your household over 60
Please Select
Yes
No
Is a member of your household in receipt of benefits
Please Select
Yes
No
Your Energy Use And Suppliers
Electricity Use Per Quarter KWh (Units On Your Bill)
Gas Use Per Quarter KWh (Units On Your Bill)
How Much Do You Spend On Electricity Per Year £
How Much Do You Spend On Gas Per Year £
Is the building connected to the national grid
Please Select
Yes
No
Who is your current electricity supplier:
Who is your current gas supplier:
Special Building Features
Is the building listed or in a conservation area
Please Select
Yes
No
Is there any shading to the roof area
Please Select
Yes
No
Are there any penetrations in the roof area
Please Select
Yes
No
Other Information
Remarks:
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