Mold Toxicity Questionnaire

Mold Toxicity Questionnaire
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Today's Date

MonthDayYear
Date

Please select "yes" or "no" to each of the following symptoms/medical conditions. If there are options that you're not sure of, or have never heard of, please select "no".

	Yes	No
Abnormal reaction/sensitivity to medications /supplements
Allergies not well- controlled by medication
Allergies/hay fever year-round
Anemia
Aplastic anemia
Arrhythmia
Arteriovenous abnormality
Aspergillosis, past or present
Asthma or wheezing
Asthma that is difficult to control with medication
Autism or sensory processing disorder
Autoimmunity
Bacterial vaginosis
Balance issues or incoordination
Bladder infections
Bloating or flatulence
Blood in stool or digestive ulcers
Blurred vision or difficulty reading
Brain fog or reduced mental clarity
Bruising easily
Burning lungs
Cancer not otherwise specified (past or present)
Celiac or non-celiac intestinal disease
Chemical sensitivity
Chest pain
Chronic cough
Chronic fatigue syndrome
Chronic inflammatory response syndrome (CIRS) or positive Shoemaker tests
Chronic pelvic pain
Chronic sinusitis
Chronically sore throat
Churg Strauss Syndrome
Clothing irritants (Bothered by tags/seams on clothing, fabrics)
Coagulation abnormalities
Craving carbohydrates, sugary foods, or alcohol
Current exposure to mold
Cyclical vomiting syndrome
Daily use of sinus spray, Neti pot, or sinus-related prescriptions
Dark circles under eyes
Dementia
Difficulty sleeping
Difficulty walking/unstable gait
Disorientation or confusion
Dizziness, vertigo, or drunken sensation
Dysautonomia or Postural Tachycardia Syndrome (PoTS)
Ear ringing or ear pain that’s new or worsening
Ears feel plugged or clogged
Easily irritated lungs
Eczema or psoriasis
Edema in lower extremities
Eosinophilic esophagitis
Episodes of fast heart beat
Episodic cough
Epstein-Barr virus activation
Erythema nodosum
Excessive thirst
Eye irritation
Fatty liver
Feeling worse after eating
Feeling worse after exercise
Filmy coating on tongue
Floaters in your vision
Food sensitivities
Frequent infections or delayed recovery from colds
Frequent throat clearing or post-nasal drip
Frequent vomiting
Headaches
Hearing loss
Heart palpitations
Heightened bodily discomfort or intensified physical pain
Heightened sensitivity to the scent of mold/mildew
Hepatocellular carcinoma or other liver cancer
Histamine intolerance
History of exposure to damp, musty or water-damaged building any time in your life
History of kidney stones
Hypermobility or Ehlers- Danlos syndrome
Idiopathic Pulmonary Fibrosis
IgA nephropathy, nephrotic syndrome, nephritis, or other kidney disease
Infertility
Internal vibrating sensation
Interstitial cystitis
Irritable bowel, constipation/diarrhea
Itchy or burning skin
Itchy or sore ear canals
Kidney cancer
Kidney pain or swelling
Light, sound, or touch sensitivity
Liver pain or swelling
Low platelets
Lung cancer
Lung scarring or lung nodules
MARCoNS
Mast cell activation syndrome (MCAS)
Memory loss of difficulty thinking clearly
Migraines
Mold allergy
Muscle weakness or spasm
Nasal polyps
Nasally sounding voice
Nausea
New or worsening nerve pain, numbness or tingling
Non-alcoholic steatohepatitism (NASH)
Non-obstructive sleep apnea
Nose bleeds
Oral sores
Oral thrush
Overactive bladder
Peanut allergy
Peeling or sloughing skin
Poor reaction to musty spaces
Prone to joint injuries
Protruding veins on limbs
Pulmonary Edema
Raynaud’s syndrome
Recent change in appetite
Recent sinusitis
Recurrent yeast infections or fungal skin infections, including athlete’s foot, jock itch or yeast vaginitis
Reduced GFR (glomerular filtration rate)
Respiratory distress or Idiopathic pneumonitis
Restlessness, feeling overwhelmed, thoughts racing
Sarcoidosis
Sensitivity to EMFs
Shortness of breath, a feeling of air depravation, or frequent yawning/sighing
Sinus surgery (any age)
Skin rash, redness or flushing
Slow reflexes
Sneezing or persistent runny nose
Strong or frequent static shocks
Stubborn weight gain
Toenail fungus
Tremors or tics
Unexplainable fatigue
Unexplained changes in digestion/bowel habits
Unexplained menstrual changes
Unexplained mood changes, anxiety, or depression

Total Score
Results:

Your score falls within the range of 0 to 4, suggesting a low likelihood that your symptoms are related to mold-related illness.
Results:

Your score falls within the range 5 to 9, which suggests a potential connection to mold-related illness.
Results:

Your score falls within the range of 10+, suggesting a high likelihood of mold or biotoxin-related illness.
Should be Empty: