tell us about yourself:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
*
Please Select
Doctor
Facebook
Friend or Family member
Other
Please Specify
*
Approximate year was your home built?
What year did you move into your home?
Health Related Questions.
Are you experiencing any of the following health concerns?
Brain Fog
Fatigue
Unexplained weight gain
Gastrointestinal issues
Chronic sinus issues
Skin rashes
Joint pain
Hair loss
Thyroid issues
Children with unexplained rage
Headaches
Numbness & Tingling
Short Temper
Electrical Shock Pain
Elevated Heart Rate at Rest
Other
Do you feel better when you leave your home for an extended period of time?
Yes
No
Maybe
Any allergies to medications?
Have you been tested for MTHFR defects? If so, which variant?
Please Select
Have you been tested for MTHFR defects? If so, which variant?
C677T
A1298C
Both
Unsure
Do you have any autoimmune diseases?
Myasthenia Gravis
Multiple Sclerosis
Systemic Lupus
PANS / PANDAS
POTS
Chronic Inflammatory Demyelinating Polyneuropathy
Rheumatoid arthritis
Sjögren's syndrome
Fibromyalgia
Sarcoidosis
Hypogammaglobulinemia or any immune deficiency
Other
Cancer. What Type?
Have you had urine mycotoxin testing?
Yes
No
Do you know your current Vitamin D level?
Home Related Questions.
Have you had any water intrusion issues since moving into your home? (plumbing leaks, roof leaks, floods, etc.) If so, please explain.
Yes
No
Please describe water damage or any water occurrence issues, approx. year and location/s:(ex; plumbing leaks, roof leaks, floods, etc.)
Please check if you have any of the following in your home.
Basement
Crawlspace
Attic
Do you have floorplans that you can provide us?
Yes
No
Maybe
What type of Heating do you have in your home?
Forced Hot Air
Electric Heat
Hot water Baseboard
Oil Baseboard
Radiator Heat
If you have Forced Hot Air, Please answer the following questions.
Where is your HVAC system located?
Attic
Basement/Crawlspace
Utility Closet
Utility Closet
What is the approximate age of your HVAC system?
When was the last time your ductwork was cleaned?
If you have Electric, Hot water baseboard, Oil baseboard, or Radiator Heat, Please answer the following questions.
What type of cooling system do you have in your home?
Central A/C
Window Units
Wall Units
If you have Central Air, Please answer the following questions.
Where is your Air Conditioning system located?
Attic
Basement/Crawlspace
Utility Closet
Garage
Other
Do you have a media filter / Air purification system attached to the HVAC system?
Yes
No
Usure
Do you have any other information you would like to share?
Any other information you would like to share.
Please upload any previous mold-related test results, seller disclosure, and/or inspection report.
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