Mold Survey - Mold Herbs

What is your name?*

First Last

What is your date of birth ?*

What is your address?*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Have you ever lived or worked in a place that was*

Please provide details*

(max 200 words)

Have you ever performed any tests for mold?*

Please provide details*

What kind of heating system do you have?*

How many adults live in the same home as you?*

(excluding yourself)

How many infants live in the same home as you?*

How many children live in the same home as you?*

Is anyone in the household experiencing mold symptoms?*

Please provide details*

(max 200 words)

Have you or anyone else in your household experienced any changes in vision recently?*

Please provide details*

(max 200 words)

Are you or anyone else in your household experiencing any of the following?*

Please explain*

(max 400 words)

If you wish Ingrid to comment on the information provided, please include your e-mail.

(max 500 words)

Email

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