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MyHomeMyHealth Client Intake Form
Name
Email
Phone
Address
Own or Rent/Lease
Own
Rent/Lease
Please have the owner contact us to schedule an inspection
Home or Building Design
Square footage of space
Build Year
Duration of Residence
Carpeting? If yes, when was carpet installed?
Type of foundation:
Near Water?
Are you the original owner?
Are you the original owner?
Were there any comments on the seller’s property disclosure regarding water events?
Since owning the property, have you experienced any water damage/intrusion episodes? (Regardless of severity)
Do you have any building plans and floor plans available?
Have you had any remodeling or building additions?
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What type of HVAC system do you have?
How many units?
What zones?
How old?
Have ducts been replaced or cleaned?
Regular Servicing?
Where are the filters?
Central filter or on returns only?
What type of rating?
Replaced by occupant or service company?
When was the last time the ducts were cleaned?
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What is the average humidity in the home?
Is there an attached garage, utility room, or shed?
Are any chemicals being stored indoors?
Have you ever seen or suspected mold growth on any surfaces in the living space or on any furnishings, clothing, shoes, other items?
Any specific concerns related to mold and moisture:
Do you have indoor pets? If so, please detail.
Are there any areas you have noted to be musty or odd smelling?
Are there any areas where your symptoms or other occupant symptoms seem to be worse?
Are there areas you or sensitive occupants feel best?
Do you have symptoms that started in this home? If so, when? Describe.
Do any symptoms tend to worsen at home and lessen when away for a while? If so, describe.
Does it make a difference in symptoms if the HVAC is running or off?
Are symptoms seasonal? If so, describe.
Have you had previous homes with mold, mustiness, water leaks, or possible mold exposures?
If you had water damage or mold exposure in previous homes, did you bring any furnishings or other items to this home from that home?
If you work away from home, have you noted any symptoms at work or any indications there may be mold or chemical exposures?
Do you or any family members experience sensitivities to fragrances, other odors, chemical cleaners, etc.?
Is this in the home or do you experience this in other buildings too?
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