Customer Informational Worksheet for Driveability and Intermittent Problems

Driveability and intermittent problems can be a very frustrating experience for both the customer and the technician. The more information we have, the quicker we can zero in on the diagnosis. In order to help us serve you in the most economical manner possible, please print out the form below and complete it in its entirety. If necessary, keep the form with you in the vehicle for a few days so the information needed will be fresh in your mind the next time the problem occurs. Please bring the completed form with you when you drop off your vehicle for your scheduled appointment.

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1. Name:
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2. Address:
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3. Phone and Pager Numbers: (where you can be reached during the day)
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4. Vehicle: (year, make, model)
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5. Vehicle Symptoms/Description:
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6. When did the problem first occur?
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7. Has the vehicle previously been worked on for this problem?
___ Yes ___ No
If yes, what work was done and did it make a difference?
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8. Does the problem occur when the engine is:
___ cold only ___ warm only ___ warm or cold ___ other (please explain)
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9. Does the problem occur when the weather conditions are:
___ cold only ___ hot only ___ hot or cold ___ wet only ___ dry only ___ no difference

10. At what speeds does the problem occur?
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11. Does the problem occur when you are:
___ accelerating ___ decelerating ___ cruising

12. Have you noticed any:
___ unusual sounds ___ odors ___drips ___ leaks ___ smoke ___ warning lights
___ gauge readings
Please explain.
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13. Have you noticed any changes in:
___ acceleration ___ engine performance ___ fuel mileage ___ fluid levels
Please explain.
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14. Any problems with:
___ handling ___ braking ___ steering ___ vibrations
Please explain.
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15. How often does the problem occur?
___ every time the vehicle is driven ___ once a day ___ once a week ___ randomly
If randomly, please explain as specifically as possible.
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16. What is the longest period of time, in normal use, during which you did not notice the problem?
___ 1 hour ___ 1 day ___ 1 week ___ other
If other, please explain.
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17. Other helpful information:
___ Yes ___ No Has the vehicle been sitting for a long period of time?
If yes, how long? __________________________
___ Yes ___ No Is the vehicle normally garaged?
___ Yes ___ No Is the vehicle normally driven only on short trips? (less than 2 miles)
___ Yes ___ No Has the vehicle ever been in an accident?
If yes, what parts were damaged?
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___ Yes ___ No Has the vehicle been stolen/recovered recently?
___ Yes ___ No Have you ever noticed wet carpeting?
___ Yes ___ No Has the vehicle ever been in a flood?
___ Yes ___ No Does the vehicle have a salvage title?
___ Yes ___ No Has the vehicle just had body work or other repairs?
If yes, please explain.
________________________________________________________________________________ ________________________________________________________________________________
___ Yes ___ No Has a stereo or other accessory been installed recently?
If yes, please explain.
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___ Yes ___ No Does the vehicle's radio have static?
___ Yes ___ No Are there any electrical accessories that do not work?
If yes, please list them.
________________________________________________________________________________
___ Yes ___ No Have you noticed any electrical abnormalities?
If yes, please explain.
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___ Yes ___ No Did the problem occur shortly after purchasing fuel?
___ Yes ___ No Did you recently change brands of fuel?
___ Yes ___ No Any raw fuel odor?
___ Yes ___ No Did the problem occur after loaning the vehicle to someone?
___ Yes ___ No Does the temperature gauge/light ever show overheat?
___ Yes ___ No Does the temperature gauge (if equipped) show lower than normal temperature,
even after driving 20-30 minutes?
___ Yes ___ No Does the heater take a long time to put out hot air?
___ Yes ___ No Is the vehicle equipped with any anti-theft device/alarm?
If yes, does it work? ___ Yes ___ No
___ Yes ___ No Does the vehicle have a hidden "kill" switch?

18. Please provide any other information that you feel might be useful (even if it seems inconsequential) on a separate sheet of paper.

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