| | Your Email Address: * | | | |
| | Your Name: * | | | |
| | Computer Manufacturer: * | | | |
| | Computer Model: * | | | |
| | Windows Version: * | | | |
| | Runs Slow: | | Don't Know No Yes | |
| | Viruses, SpyWare, AdWare: | | Don't Know No Yes | |
| | Hacked: | | Don't Know No Yes | |
| | Programs Stop Working: | | Don't Know No Yes | |
| | Blue Screen of Death: | | Don't Know No Yes | |
| | Computer Purchased: | | |
| | Last Computer Maintenance: | | |
| | Last Computer Backup: | | |
| | Daily Computer Usage: | | |
| | Personal or Business Usage: | | |
| | Who Uses the Computer: | | |
| | Do You Use a Firewall: | | Don't Know No Yes | |
| | Do You Use Anit-Virus Software: | | Don't Know No Yes | |
| | Surf the Internet: | | Don't Know No Yes | |
| | Download Video, Music, Pictures, etc.: | | Don't Know No Yes | |
| | Send and Receive Email: | | Don't Know No Yes | |
| | Email Documents and Other Files: | | Don't Know No Yes | |
| | Chat (AIM, Yahoo, MSN, Google): | | Don't Know No Yes | |
| | YouTube, Facebook, MySpace: | | Don't Know No Yes | |
| | AOL Service: | | Don't Know No Yes | |
| | Microsoft Word: | | Don't Know No Yes | |
| | Microsoft Excel: | | Don't Know No Yes | |
| | Microsoft Powerpoint: | | Don't Know No Yes | |
| | Microsoft Access: | | Don't Know No Yes | |
| | Microsoft Outlook: | | Don't Know No Yes | |
| | Microsoft Works: | | Don't Know No Yes | |
| | iTunes, Microsoft Media Player: | | Don't Know No Yes | |
| | Quicken, QuickBooks, MS Money: | | Don't Know No Yes | |
| | Wordperfect Office: | | Don't Know No Yes | |
| | Lotus SmartSuite: | | Don't Know No Yes | |
| | Photo, Graphic Editing: | | Don't Know No Yes | |
| | Video Editing: | | Don't Know No Yes | |
| | Music Editing: | | Don't Know No Yes | |
| | Complaints and Symptoms: | | |
| | Additional Information: | | |
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