Cornerstone Mold
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Health Survey
HEALTH SURVEY
Name
Phone
Email
Have you experienced any of these symptoms?
Coughing
Chronic Bronchitis
Asthma
Nausea
Diarrhea
Heart Palpitations
Weight Loss/Weight Gain
Chronic Fatigue
Sexual Dysfunction
Have you experienced any of these symptoms?
Headaches
Eye Irritation
Sneezing
Itching
Memory Loss
Blurred Vision
Ear Infections
Chronic Sinusitis
Nose Bleeds
Have you been diagnosed with any of these ailments?
Fibromyalgia
Rheumatoid Arthritis
Inflammation
Lupus
COPD
Hypersensitivity Pneumonitis
Lyme Disease
Cancer
Histoplasmosis
Have you had any water leaks in the environment?
Yes
No
Do you see any water stains on the walls or ceiling?
Yes
No
Is there visible mold growth on the wall, ceiling, or floors?
Yes
No
Does your environment have elevated humidity?
Yes
No
Have you noticed any musty or mildew smells in the environment?
Yes
No
SUBMIT SURVEY
HEALTH SURVEY
Name
Phone
Email
Have you experienced any of these symptoms?
Coughing
Chronic Bronchitis
Asthma
Nausea
Diarrhea
Heart Palpitations
Weight Loss/Weight Gain
Chronic Fatigue
Sexual Dysfunction
Have you experienced any of these symptoms?
Headaches
Eye Irritation
Sneezing
Itching
Memory Loss
Blurred Vision
Ear Infections
Chronic Sinusitis
Nose Bleeds
Have you been diagnosed with any of these ailments?
Fibromyalgia
Rheumatoid Arthritis
Inflammation
Lupus
COPD
Hypersensitivity Pneumonitis
Lyme Disease
Cancer
Histoplasmosis
Have you had any water leaks in the environment?
Yes
No
Do you see any water stains on the walls or ceiling?
Yes
No
Is there visible mold growth on the wall, ceiling, or floors?
Yes
No
Does your environment have elevated humidity?
Yes
No
Have you noticed any musty or mildew smells in the environment?
Yes
No
SUBMIT SURVEY
