Lifespan Mold Health Survey

1
On a scale of 1 to 10, how debilitating are your chronic health issues? * This field is required.(1 = Barely noticeable, 10 = Completely life-altering)
1
2
3
4
5
6
7
8
9
10
Worst
Best
2
Select all symptoms you experience frequently:* This field is required.
Chronic Fatigue
Brain Fog/Memory Loss
Deep Muscle Aches
Joint Aches
Persistent Sinus Issues
Headaches/Migraines
Unexplained Skin Rashes/Eczema
Persistent Digestive Issues (Acid Reflux, Diarrhea)
Tightness in the Chest
Loss of Concentration
Unusual Hair Loss
Depression
Numbness/Tingling in Lips or Tongue
3
Have you sought medical treatment for these symptoms without a clear or helpful diagnosis?* This field is required.
YESNO
4
Do you generally feel significantly BETTER when you leave your home for an extended time (e.g., on vacation, at a friend's house)?* This field is required.
YESNO
5
Do your symptoms generally feel WORSE when you return to your home?* This field is required.
YESNO
6
Have you noticed any unusual or persistent odors in your home (musty, earthy, dirty laundry, sour)?* This field is required.
YESNO
7
Was the start of your symptoms correlated with a known moisture event (e.g., flood, leaky roof, burst pipe)?* This field is required.
YESNO
8
What is the approximate size of the property in square feet?
9
What type of property is this?* This field is required.
Please Select
Please Select
Single-Family Home
Multi-Unit Building
Commercial/Office
RV/Vehicle
Other
10
Does the property have a crawl space or unfinished basement?* This field is required.
YESNO
11
Do you find you have to dust every 3 days or less to stay dust-free?* This field is required.
YESNO
12
Have you ever seen mold or mildew any place in the building (even in a small area like a bathroom corner)?* This field is required.
YESNO
13
What room or area is the odor or mold/mildew strongest?
14
Please briefly describe your specific situation or primary concern.
Huge
Large
Normal
Small
Ok
Ok
15
Name* This field is required.
First Name
Last Name
16
Email* This field is required.
example@example.com
Email Verified
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17
Phone Number
Please enter a valid phone number.
18
Best time for our team to call you to discuss your confidential results?
Please Select
Please Select
Morning (9am-12pm)
Afternoon (12pm-4pm)
Evening (4pm-7pm)
19
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I agree to the Privacy Policy
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