Customer Diagnostic Survey Form


Client Name: ____________________________             Date: ____________________


Car Make/Model:____________________________       Licence #: ________________



IT HAPPENS WHEN…                                          DEFINE THE PROBLEM…


VEHICLE OPERATION                                 THE PROBLEM STARTED


­­__ Vehicle is not moving (engine running)                 __Suddenly at ________ (odometer)          

__ Vehicle is moving during the following                      __Gradually at _______  (odometer)          

      operation(s)                                 __ Just started   _______ (odometer)          

__ Light to medium acceleration                                 __ Since the vehicle was new

__ Hard acceleration                                 __ After abnormal occurrence (i.e.

__ Deceleration (coast in gear)                                        pot holes, curb impact)

__ Deceleration (coast out of gear)

__ Cruising (constant highway speed)                      THE PROBLEM OCCURS

__ Braking

__ Turning                                                          __Rarely  __Sometimes  __ Always

__ With vehicle occupants (or heavy load)


SPEED OF VEHICLE                                        Are there any unusual noises?

Describe the speed at which the problem                             ___ yes    ___ no


Vehicle speed ______________ km/h                     Is there any vibration? __yes __no

Engine speed                                                          If yes, please describe the noise

__ Idle      __ Medium      __ High                                  and/or vibration and where it

                                                                             seems to be coming from.

ROAD TEST                                                         

Describe the speed at which the problem occurs    ____________________________

Vehicle speed _____________ km/h                                        


Vehicle RPMs ________

Road test indicated the following:                                 ____________________________

__ Engine check

__ Engine accessory check                                     ____________________________

__ Wheel and Tire check

__ Engine Mount check

__ Drive Train check

__ Body check

__ Other                                                                      


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