Mold Inspection Questionnaire Mold Inspection Questionnaire Please fill out this questionnaire below regarding your mold inspection serviceName* First Last Email* Phone*How did you hear about us?* Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupancy* Square Footage* How many bedrooms?* Are you working with a mold remediation contractor?*SelectYesNoIf Yes, who are you working with? Have you experienced a water event?*(Plumbing leak, sump pump failure, seepage, condensation, etc.)SelectYesNoIf Yes, please explain the type of water event and how did you address it?*Do you have visual mold growth?*SelectYesNoIf Yes, please explain?*Are you or anyone else experiencing health issues suspected to be related to mold exposure?*SelectYesNoIf Yes, please explain?*Do you feel better when you leave and worse when you come back?*SelectYesNoHave you done any medical testing that indicate you are exposed to mold?*SelectYesNoIf Yes, please explain?*Have you done a mold test on your own?*SelectYesNoWhat were the results of your mold test?*Is this an insurance claim?* Anything else you would like to tell us?CommentsThis field is for validation purposes and should be left unchanged. Δ