Personal Information
Last Name: _______________ First Name: _______________
Maiden Name: _______________
Other names used___________________________________
Contact Information
Email address_______________
Home phone number _______________
Work phone number _______________
Home address:
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Please answer the following to the best of your ability:
I suspect a mold problem at:
____My place of business
____My home
____Other
If the suspected mold problem is at your home, when was the home built?______________
If you did not build your home, when did you purchase it?_______________
Please place an “X” next to any of the following warningsigns if you have noticed them at your home or place of business:
____Visible mold growth
____Discoloration or water stains on internally facing walls or ceilings
____Discoloration or water stains on externally facing walls
____Areas of standing water or condensation on floors, walls, or window sills
____Musty odor
Please place an “X” next to any of the following health effectsif you have experienced them:
____Worsening of allergies
____Respiratory problems
____Fever
____Nasal and sinus congestion
____Burning / watering eyes
____Worsening of asthma
____Coughing
____Sore throat
____Flu-like symptoms
____Skin irritation
____Headaches
Please list the name of the General Contractor who built your home (ifapplicable):
___________________________________________
___________________________________________
Any other information or concerns?
_______________________________________________
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