Client/Patient Onboarding Questionnaire Client Onboarding Questionnaire Occupants’ health & risk factors Higher‑risk occupants in the residence (check all that apply) Newborns / infants / toddlers Pregnancies Post‑pubertal females Compromised immune systems Elderly Small indoor pets (< 20 lbs) CIRS / mold‑sensitized / highly allergenic Auto‑immune / co‑morbidities (esp. Lyme) Symptoms experienced (check all that apply) Eczema or rashes Respiratory / sinus issues Fatigue or brain fog GI issues Sleep disruptions Other suspected symptoms Any animal health challenges? Previous residential history Years in current residence Any known mold exposure or symptoms in previous residence? Yes No Was the home previously a rental or investment property? Yes No Did previous occupants experience environment‑related health issues? Yes No Was personal property relocated from the previous residence? Yes No Time spent away from residence Do symptoms improve or worsen when away? Improve Worsen N/A Do symptoms return when back home? Yes No N/A Clinical treatment & mold exposure testing Any occupant currently treated by a functional or environmental practitioner? Yes No Clinical tests indicating mold exposure (check all that apply) Urine mycotoxin (MycoTOX / RealTime) IgG / IgE mold panel OATS (Organic Acids Test) HLA‑DR / genetic markers MARCoNS nasal culture Other Previous environmental testing Previous mold testing performed (check all that apply) Previous assessment report Post‑remediation clearance ERMI / HERTSMI‑2 Petri dish / viable plates Other Home tested for radon or other gases? Yes No Areas suspected to have mold Select suspected areas (check all that apply) Crawlspace / basement HVAC system / ducts Cabinets Kitchen Bathroom Laundry room Other Recent lifestyle / home changes Which of the following changes have occurred recently? (check all that apply) Remodeling / construction Painting New flooring New furniture Lawn or landscape treatments Pest control treatments Change in cleaning products Change in laundry products Other Previous water damage / ground‑water intrusions Select all sources of water intrusion (check all that apply) Plumbing leaks Water heater Dishwasher Refrigerator / ice maker Clothes washer Roof leaks HVAC condensate drain HVAC condensation Window / door leaks Indoor humidity > 60 % Standing water / drainage issues Clogged gutters / French drains Crawlspace flooding Clear form Download PDF
