First Name *

Last Name *

Date of birth *

Exposure Environment

Have you recently lived, worked, or spent significant time in a place where you suspect mold exposure? *

Yes, in my home or apartment

Yes, at my workplace or school

Yes, in both home and work environments

No known exposure

Unsure, but I’ve noticed water damage or musty smells

Building or Housing Conditions

Have you noticed any of the following issues in your current or previous residence? *

Visible mold growth on walls, ceilings, or vents

Musty or earthy odor indoors

Water leaks or plumbing problems

Past flooding or water damage

Condensation on windows or walls

Discoloration or bubbling paint

Moldy smell when HVAC runs

None of the above

Timeline of Symptoms vs. Location

Do your symptoms improve or worsen depending on your location? *

Symptoms worsen at home and improve elsewhere

Symptoms occur everywhere

No noticeable difference

Unsure

Household Impact

Respiratory Symptoms

Have you experienced any breathing or sinus issues while living or working indoors? *

Neurological & Cognitive Symptoms

Have you noticed any changes in memory, focus, or mood possibly related to your environment? *

Skin, Eyes & Mucous Membranes

Have you had any skin, eye, or throat irritation that worsens indoors? *

Digestive & Systemic Symptoms

Have you experienced any stomach or digestive issues that you suspect may be related to mold exposure? *

Fatigue & Energy Levels

Have you noticed changes in your energy or overall stamina while living or working in a mold-affected space?

Immune & Long-Term Health

Have you noticed increased illness or immune problems that seem to occur more often at home? *

Frequent colds or flu-like symptoms

Recurring infections (sinus, ear, or respiratory)

Worsening of autoimmune conditions

Allergic reactions without clear cause

Sensitivity to odors or chemicals

Slow recovery after illness

Swollen lymph nodes or inflammation

None of the above

Management Notification

Have you spoken to your management company about mold in your residence? *

Yes

Does not apply

Legal Representation

Have you spoken to a lawyer?

Yes, they have accepted my case

Yes, but i have not found representation

No, I need one

No, I do not want one.

Email *

Phone *

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