Mold health Assessment

First Name *

Last Name *

Phone *

Email Address *

Street Address

Apartment, suite, etc

City *

State/Province

ZIP / Postal Code

CountrySelect country

Current Occupancy StatusOwnRentCurrent Occupancy Status

General Mold Background

Have you noticed any visible signs of mold in your home? (Check all that apply) *

Black spots on walls / ceilingsMusty odorWater stains on ceilings or wallsPeeling paint or wallpaperVisabile mold growth in the bathroom, kitchen , or other areasOtherHave you noticed any visible signs of mold in your home? (Check all that apply)

When did you first notice signs of mold in your home? *

Month2

Day12

Year2025

When did you first notice signs of mold in your home?

Water Intrusion

Has your home experienced any water leaks or flooding in the past? (Check all that apply) *

Roof LeaksPlumbing LeaksBasement FloodingAppliance LeaksOtherHas your home experienced any water leaks or flooding in the past? (Check all that apply)

If yes, please describe the extent of water damage and when it occurred: ____________If yes, please describe the extent of water damage and when it occurred: ____________

Health Symptoms

Have you or any household members experienced any of the following health symptoms that could be related to mold exposure? (Check all that apply) *

Nasal congestionSneezingCoughingWheezing or difficulty breathingSkin rash or irritationEye irritation (redness, itching, watery eyes)HeadachesFatigueOtherHave you or any household members experienced any of the following health symptoms that could be related to mold exposure? (Check all that apply)

If yes, please specify the individuals experiencing symptoms and the duration: ____________If yes, please specify the individuals experiencing symptoms and the duration: ____________

Previous Mold Testing

Have you conducted any mold testing or inspections in the past? (Check one) *YesNoHave you conducted any mold testing or inspections in the past? (Check one)

If yes, please provide details of previous testing or inspection, including results and any remediation actions taken: ____________If yes, please provide details of previous testing or inspection, including results and any remediation actions taken: ____________

Additional Elements

Please use this space to provide any additional information or comments related to mold in your home and its potential effects on self-health: ____________Please use this space to provide any additional information or comments related to mold in your home and its potential effects on self-health: ____________

Signature *

I acknowledge that the information provided in this form is accurate to the best of my knowledge, and I consent to the use of this information for assessment and evaluation purposes.

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