Mould Illness Questionnaire

Mould Illness Questionnaire

This form was developed by Dr Jill Crista (drcrista.com). This tool is intended as a clinical information aid, and is not intended to diagnose or treat disease. Items listed have been reported in mould illness patients. Not all symptoms have been proven in studies. This form takes a few minutes to complete, so if you would like to do it later just save the URL.
Please enter you name and email if you wish for us to have your information and results ready for a free 15 minute consult. Otherwise leave blank and your results will stay anomynous. Any personal health information is kept confidential
Name

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This questionnaire goes through common symptoms that occur with mould illness. Some symptoms are very general, meaning they can be caused by multiple things. Others are more unique to mould. There is also some questions about your history ie. exposure to mould. The categories are designed to give each symptom a particular score ie. some symptoms/history will have more "weight".
CATEGORY 1

Fatigue that doesn’t otherwise make senseTrouble sleepingWorse after eatingWorse after exerciseIncreased thirstStubborn weight gainAnemiaBothered by tags and seams on clothingChemical sensitivitiesSensitive to light, sound or touchSlowed thinking or brain fogUnsettled feeling, unquieted mind, overwhelmHeadachesDizziness, vertigo or drunken feelingUnexplained mood changes, anxiety or depressionAllergies/hay fever year-roundEye irritationDark circles under eyesFloaters in your visionVision blurry, frequently changes or difficulty readingSneezing or persistent runny noseAcute sense of smell for mouldRecent sinusitisEars feel plugged or cloggedItchy or sore ear canalsSores in the mouthPost-nasal drip or frequent throat clearingChronically sore throatCoated tongueEasily irritated lungsEpisodic coughShortness of breath, air hunger or yawn/sigh oftenEasy bruisingHeart palpitationsLower extremity edemaProtruding veins on limbsNauseaBloated abdomen or flatulenceUnexplained change in digestion/bowelsRecent change in appetiteCrave carbs, sweets or alcoholOveractive bladderBladder infectionsSkin rash, redness or flushingFrequent infections or delayed recovery from coldsIncreased body pain
Total symptoms
SCORE: CATEGORY 1
CATEGORY 2

Voice sounds nasallyHistamine intoleranceFrequent or strong static shocksNon-obstructive sleep apneaReact poorly to musty spacesSensitivity to EMFsMigrainesDifficulty thinking clearly or memory lossConfusion or disorientationAllergies are not well controlled by medicationChronic sinusitisNose bleedsEar ringing or ear pain that’s new or worseningAsthma or wheezingChronic coughBurning lungsEpisodes of fast heart beatChest painLow plateletsIncreased food sensitivitiesFrequent vomitingIrritable bowel or alternating constipation/diarrheaDigestive ulcer or blood in the stoolCeliac or non-celiac intestinal diseaseFatty liverLiver pain or swellingUnexplained menstrual changesBacterial vaginosisKidney pain or swellingItchy or burning skinPeeling or sloughing skinRaynaud’s syndromeEczema or psoriasisEpstein-Barr virus activationSlow reflexesBalance issues or incoordinationJoints easily injuredNew or worsening nerve pain,numbness or tinglingMuscle weakness or spasm
Total symptoms
TOTAL SCORE CATEGORY 2
CATEGORY 3

Current exposure to mouldMould allergyAbnormal reaction to medications or supplementsAutism or sensory processing disorderChronic fatigue syndromeChronic inflammatoryresponse syndrome (CIRS)or positive Shoemaker testsFeeling of an internal vibrationDysautonomia or Postural Tachycardia Syndrome (POTS)DementiaDaily use of sinus spray, sinus prescription or Neti potNasal polypsSinus surgery at any time in your lifeMARCoNSOral thrushAsthma that’s difficult to control with medicationLung scarring or nodulesPulmonary EdemaIdiopathic Pulmonary FibrosisRespiratory distress or Idiopathic pneumonitisLung cancerArrhythmiaCoagulation abnormalitiesArteriovenous abnormalityChurg Strauss SyndromePeanut allergyCyclical vomiting syndromeEosinophilic esophagitisNon-alcoholic steatohepatitis(NASH)Hepatocellular carcinoma or other liver cancerInfertilityChronic pelvic painInterstitial cystitisHistory of kidney stonesReduced GFR (glomerular filtration rate)IgA nephropathy, nephrotic syndrome, nephritis, or other kidney diseaseKidney cancerRecurrent yeast infections or fungal skin infections,including athlete’s foot, jock itch or yeast vaginitisErythema nodosumToenail fungusAutoimmunityMast cell activation syndrome(MCAS)Aspergillosis, current or history ofPrevious or current cancer diagnosis, not otherwise specifiedAplastic anemiaSarcoidosisHypermobility or Ehlers-Danlos syndromeTremors or ticsDifficulty walking
TOTAL SCORE CATEGORY 3
TOTAL MOULD ILLNESS SCORE
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Mould Illness Questionnaire

Please enter you name and email if you wish for us to have your information and results ready for a free 15 minute consult. Otherwise leave blank and your results will stay anomynous. Any personal health information is kept confidential