Personal Information
Last Name: _______________ First Name: _______________
Maiden Name: _______________
Other names used
___________________________________
Contact Information
Email address_______________
Home phone number _______________
Work phone number _______________
Home address:
_____________________________________________
________________________________________________
________________________________________________
________________________________________________
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 warning
signs 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 effects
if 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 (if
applicable):
___________________________________________
___________________________________________
Any other information or concerns?
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________