Mold Illness Questionnaire Mold Illness Questionnaire Name * Email * Phone Address * What health symptoms do you have? * Have you seen a Doctor? If so, what was your diagnosis? * YesYes No How many occupants are there in your home (Grandparents, Adults, Teens, Kids)? * What health issues do occupants have (if any)? Are there any odors that might be described as weird or strange? * Yes No Other (please explain)Other (please explain) Do you or those with symptoms live or work in a moisture compromised building (water intrusion, leaks, damp basement, history of flooding, etc)? Please describe. * Is there any suspect Visual Mold Growth (VMG) in your home? If so, where? * YesYes No Please describe rooms or areas that you avoid due to reactions or just don't feel well in. * Age of Structure. How long have you lived in the house / worked at the site? * Please describe any recent renovations on the home or work place? Upload any reports, tests, lab results, pictures or related documents that you might have. Photos / Video Drop a file here or click to upload Choose File Maximum upload size: 52.43MB Reports (pdf, doc, docx) Drop a file here or click to upload Choose File Maximum upload size: 52.43MB Lab Results (pdf, doc, docx) Drop a file here or click to upload Choose File Maximum upload size: 52.43MB If you are human, leave this field blank. Submit Δ
