How did you hear about us? Have you been referred by your physician or practitioner? HVAC contractor, remediation contractor, another one of our clients? If so, whom?
Home? Work building? Single-family, apartment etc.
When was your home built? How many years have you lived there?
What is your foundation? Slab, crawlspace, basement unfinished or finished? If basement, does anyone occupy that space as office or bedrooms?
Was the home inspected when it was purchased or since then? Do you have any reports of water intrusions or moisture issues, mold growth etc. If so, were they repaired and by whom. What was done if mold was found?
Have you had any flooding, water leaks, HVAC drain back-ups, roof leaks, crawlspace or foundation puddling, overflows of sinks tubs toilets or washer? If so, describe and indicate what was done to mitigate.
Have you ever seen mold or suspected mold growth on any surfaces in the living space or on any furnishings, clothing, shoes, other items? If so, describe.
Have you ever noted the home to be humid or clammy damp especially in the summer? Do you have a humidity monitor? What is the humidity in the summer months on average?
How many HVAC units does your home have? What zones do they supply? How old are they? Have the ducts ever been replaced or cleaned? If so, describe. Do you get regular HVAC servicing?
Where are the filters for your HVAC units? ie central filter on handler or filters at each return? What type or rating are they? Do you replace them regularly or do you have a service company replace them?
Are there any areas of the home you have noted to be musty or odd smelling? Are there any areas where your symptoms or a family member's symptoms seem to be worse? Are there areas you or sensitive occupants feel best?
Do any symptoms tend to worsen at home and lessen when away for a while? If so, describe. Does it make a difference in symptoms if the HVAC is running or off?
Are symptoms seasonal? If so, describe.
Do you have symptoms that started in this home, if so when? Describe.
Have you had previous homes with mold, mustiness, water leaks or possible mold exposures? If so, describe.
If you had water damage or mold exposure in previous homes did you bring any furnishings or other items to this home from that home? If so, describe and were they professionally cleaned?
If you work away from home have you noted any symptoms at work or any indications there may be mold or chemical exposures?
Do you or any family members experience sensitivities to fragrances, other odors, chemical cleaners, etc. Is this in the home or do you experience this in other buildings too?
NOTE: the following form questions are not HIPAA compliant.
Are you or a family member under the care of a physician who has indicated you have mold-related illness or symptoms? If so, have you had lab testing to verify? If so, describe.
Are you or a family member under any specific treatments for mold or bio-toxin illness, CIRS, Lyme or auto-immune disorders?
Have you or any family members under treatment been experiencing improvements in symptoms and clinical testing?
If you are have not been verified or tested for mold-related illness can you describe symptoms you or your family members have been experiencing?