First Name *

Last Name *

Birth Date

Email *

Phone *

Instructions:

✔️ Check all that apply.

Section 1: Environment & Exposure

I have lived or worked in a building with visible mold

I notice a musty or earthy smell in my home, car, or workplace

My home/workplace has had water damage (leaks, flooding, dampness)

I feel better when I am away from my environment for 48+ hours

I live/work in an older building without mold remediation or updates

Section 2: Energy & Neurological Function

I experience fatigue not relieved by rest

I have brain fog, memory issues, or trouble focusing

I get frequent headaches or migraines

I feel dizzy, off-balance, or not fully grounded

Section 3: Respiratory and Sensitivity

I experience fatigue not relieved by rest

I have brain fog, memory issues, or trouble focusing

I get frequent headaches or migraines

I feel dizzy, off-balance, or not fully grounded

Section 4: Immune, Pain & Inflammation

I get frequent colds or infections, or recover slowly

I have unexplained joint or muscle pain

I experience swelling, puffiness, or unexplained weight gain

Section 5: Digestive & Detox

I experience bloating, constipation, diarrhea, or abdominal discomfort

I have food sensitivities or intolerances

I feel worse after foods like corn, peanuts, soy, or grains

Section 6: Mood & Sensory

I experience anxiety, irritability, or mood swings without clear cause

I am sensitive to light, sound, or temperature changes

Total Score:

Scoring (Educational Use Only)

0–4 checks:

Lower likelihood based on this screening.

5–9 checks:

Possible mold-related involvement.

10+ checks:

Higher likelihood of mold/mycotoxin exposure—consider professional guidance.