Mold Symptom Assessment Survey
Help us assess the impact of mold exposure by sharing your symptoms and environment details.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
What is your age group?
*
Please Select
Under 18
18-29
30-44
45-59
60 or older
Have you noticed visible mold or a musty smell in your home or workplace?
*
Yes, visible mold
Yes, musty smell only
No
Not sure
How long have you been in the environment where you suspect mold exposure?
*
Please Select
Less than 1 month
1-6 months
6-12 months
1-5 years
More than 5 years
Please indicate which of the following symptoms you have experienced in the past month. Select all that apply.
*
Coughing
Sneezing
Wheezing or shortness of breath
Runny or stuffy nose
Itchy or watery eyes
Skin irritation or rash
Headaches
Fatigue
Other
Please rate the severity of your symptoms over the past month.
*
Rows
None
Mild
Moderate
Severe
Coughing
1
2
3
4
Sneezing
5
6
7
8
Wheezing or shortness of breath
9
10
11
12
Runny or stuffy nose
13
14
15
16
Itchy or watery eyes
17
18
19
20
Skin irritation or rash
21
22
23
24
Headaches
25
26
27
28
Fatigue
29
30
31
32
Have you ever been diagnosed with allergies, asthma, or other respiratory conditions?
*
Yes, allergies
Yes, asthma
Yes, other respiratory conditions
No
What actions have you taken regarding the suspected mold exposure?
Cleaned the area myself
Hired a professional
Reported to landlord/property manager
No action taken
Other
Please provide any additional comments or details about your symptoms or environment.
Submit Assessment
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