Client Intake Form – My Home My Health

MyHomeMyHealth Client Intake Form

Name

Phone

Address

Do you own or rent the property?

Please have the owner contact us to schedule an inspection

How did you hear about us?

Name of physician you are working with in relation to environmental exposure

Build Year

Duration of Residence

Square footage of living space

Do you have an attic or crawlspace? If so are they accesable?

Are there any disclosures related to mold or water damage from previous owners?

Are there any episodes of water infiltration during your time living here, no matter how minor? Please be specific about when, where, and what was don to remedy. Please attach any documents, inspections, lab reports below.

File Upload not required

Have you completed any remodeling work?

What type of flooring does the home have?

File Upload not required

What type of HVAC system do you have?

When was the last time the ducts were cleaned?

When was the last time the ducts were serviced?

Where is the HVAC unit located?

File Upload

Do you have cleaning services?

If yes, do they use your equipment or their own?

Are there any pets in the home?

Please list any sensitivities to chemicals and cleaning products

Do you feel better outside the home or when traveling?

Are there any specific concerns that you would like to share with us?

MyHomeMyHealth Client Intake Form

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