| Customer Info |
| First Name
Last Name Date |
| Home Phone
Cell Phone eMail |
| Street Address
City Zip Code |
Vehicle Info |
| Make
Model Year |
Towing |
|
No Towing Required
Yes I Need A Tow Please |
Starting |
|
Starts OK
Won't Crank Cranks, Won't Start Hard Start, Long Crank |
| Unusual Sound, Describe |
Dash Indicator Light On |
|
No
Check/Service Engine Alternator Temperature Other |
| Other Light, Describe |
Engine Idle |
|
OK
Too Slow Too High Rough/Unsteady Fluctuates Slow w/AC On |
Engine Running Condition |
|
OK
Rough Pings, Knocks Lacks Power Backfires |
| Hesitates During Acceleration Poor Fuel Economy Runs On After Key Off Other |
| Other, Describe |
Engine Stalls/Quits |
|
Never
Right After Starting While Idling When Shifting Into Gear While Accelerating |
| While Decelerating, Braking Coming To A Stop, Parking Random, Unpredictable |
Transmission (Automatic) |
|
OK
Hard Shifting, Jerks Shifts Early Shifts Late Changes Gear When It Shouldn't |
| Vehicle Fails To Move When In Gear |
Handling |
|
OK
Steering Pulls To Left Steering Pulls To Right Steering Loose, Drifts |
| Hard Steering Vehicle Shakes |
Smells, Odors? |
Noises, Sounds? |
Smoke? If So, What Color? |
How Often Does Problem Occur? |
|
Rarely
Sometimes Often All The Time |
Problem Occurs When Engine Is: |
|
Cold
Normal/Warm Hot All Temperatures |
Problem Occurs At These Vehicle Speeds |
|
In Park, Or Drive Stopped
Low, Under 35 MPH Cruising, 35 to 55 MPH High, 55+ MPH |
How Long Has Problem Existed? |
Driving Habits |
|
Mix
Mostly City Mostly Highway |
Roads / Terrain |
|
Mix
Mostly Paved Mostly Dirt/Gravel Some Off Road (4x4) |
Miles Driven Per Day? |
Fuel Used |
|
Regular
Unleaded Premium Unleaded E85 Diesel |
Comments, Additional Information:
|
