Customer Diagnostic Survey Form
VIBRATION
Client Name: ____________________________ Date: ____________________
Car Make/Model:____________________________ Licence #: ________________
IT HAPPENS WHEN… DEFINE THE PROBLEM…
__ Light to medium acceleration Please check the box that best describes
__ Hard acceleration the vibration you feel:
__ Deceleration (coast in gear)
__ Deceleration (coast out of gear) __ Wobble (side to side)
__ Cruising (constant highway speed) __Shake (usually caused visual movement)
__ Braking __ Pumping (usually very slow movement)
__ Turning __ Harshness (stiffness, loss of ride quality)
__ All of the above
SPEED OF VEHICLE
Please check the box that best describes
Describe the speed at which the where you feel the vibration:
Problem occurs _______ km/h __ Steering Wheel
Engine Speed __ Seat
__ Idle __ Medium __ High __ Floor
__ All of the above
ROAD CONDITIONS
If none of the above, please describe where
Describe the road conditions on the vibration seems to be coming from:
which the problem occurs:
__ Paved (rough) __ Wet ____________________________________
__ Paved (smooth)
__Going over bumps ____________________________________
__ Other______________________
____________________________________
THE PROBLEM STARTED…
__Suddenly at ____________(odometer)
__ Gradually at ___________ (odometer)
__ Just started _____________ (odometer)
__ Since the vehicle was new
__ After abnormal occurrences (ie potholes, curb impact)
THE PROBLEM OCCURS
__ Rarely __ Sometimes __ Always
Have the tires been balanced? __ Yes __ No
Were any repairs performed prior to the condition occurring? __ Yes __ No