Environmental History Survey
In order to discover if you are susceptible we need some information about some of your past medical history, please take your time and answer all the questions.
Personal Information
All information is required.
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone:
Email:
 
Environmental History
Has the heater location in your home ever been damp?
Is the heater located in a dirt crawl space?
If the heater located in a dirt crawl space, is the crawl space damp?
Is the heater located in the attic with blown-in insulation?
Do you have a humidifier in the central furnace?
Have you ever had a leak or flood anywhere – roof, basement, water heater, sink, water bed, washer?
Do you ever notice a musty smell in the house?
Have you ever noticed any mold or water stains in the house?
Do you have live plants in the bedroom or home?
Is there a particular room or area of the home where you feel worse?
Is there a particular time of day you feel worse?
Do foods, alcohol, smoke and/or chemicals trigger symptoms?
Do you or co-workers feel bad at the office?
Do you feel better away from home or away from the office?
Do you fly or stay in hotels frequently?
Do you feel better if you go to the beach or other clean air space?
Is there a musty odor in your car when you turn on the car air system?
Do you or anyone else in your home smoke?
Do you have pets in your home?
Do you sleep with pets?
 


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