Contact Us
How to Find Us
0425 717 407
Toggle navigation
Home
About
Services
Our Clinic
Blog Posts
Resources
Questionnaires
Books
Cookbooks
Going gluten-free
Green Living
LIfestyle Advice
Testimonials
Courses
Shop
Contact
Mould Illness Questionnaire
Mould Illness Questionnaire
Name
Name
First
First
Last
Last
Email
Date
Text
Text
This exposure may be past. So treat Questions 1,2 &3 as ‘have you ever’.
1. Do you live, work or drive a car that has had a water leak?
yes
no
2. Do you live in areas that flood?
yes
no
3. Do you live in a humid climate where humidity is often above 70%?
yes
no
4. When you are out walking are you very sensitive to the smell of mould?
yes
no
5. Do your symptoms flare if you have smelt mould?
yes
no
6. Do you see bubbling on your walls from water?
yes
no
7. Do you have peeling paint or wallpaper on your walls, stains on ceiling, carpets or furnishings from water?
yes
no
8. Are your symptoms worse on rainy days?
yes
no
9. Have you had infestations of rodents, cockroaches or termites?
yes
no
Text
1. Do you have abdominal pain?
yes
no
2. Do you have constipation/diarrhoea or changes in bowel movements?
yes
no
3. Do you have food sensitivities
yes
no
4. Irritable bowel
yes
no
5. Gas
yes
no
6. Bloating
yes
no
7. No appetite
yes
no
8. Crave sugar or alcohol
yes
no
Text
1. Frequency (frequent urination)
yes
no
2. Urgency (when bladder is full you have to go immediately)
yes
no
3. Recurrent UTI’s (urinary tract infections)
yes
no
Text
1. Do you suffer histamine issues
yes
no
2. Do you frequently get hives
yes
no
3. Do you have sinus, post nasal drip
yes
no
4. Swollen glands
yes
no
5. Frequent blowing of nose
yes
no
6. Hay fever
yes
no
7. Sneezing
yes
no
8. Nose bleeds
yes
no
9. Irritated or red eyes
yes
no
10. Dark circles under the eyes
yes
no
Text
1. Brain fog
yes
no
2. Sensitivity to light
yes
no
3. Sensitivity to change in temperature
yes
no
4. Headaches
yes
no
5. Anxiety
yes
no
6. Depression
yes
no
7. Feeling overwhelmed
yes
no
8. Sleep disturbance
yes
no
9. Dizziness or vertigo
yes
no
Text
1. Heart palpitations
yes
no
2. Shortness of breath
yes
no
3. Chronic cough
yes
no
4. Irritated lungs
yes
no
5. Nasal polyps
yes
no
Text
1. Fatigue
yes
no
2. Joint pain
yes
no
3. Vision problems
yes
no
4. Hard to recover when sick or frequently getting colds
yes
no
5. Static shocks
yes
no
Text
Which conditions do you suffer?:
1. Unusual pains
yes
no
2. Metallic taste in the mouth
yes
no
3. Excessive thirst
yes
no
4. Wheezing
yes
no
5. Asthma
yes
no
6. Period pain or heavy bleeding
yes
no
7. Numbness and tingling
yes
no
8. Chronic sinusitis
yes
no
9. Migraines
yes
no
10. Yeast infections – thrush, candida, tinea, jock itch
yes
no
11. Estrogen dominance – weight gain, endometriosis, fibroids, heavy periods, breast or prostate cancer
yes
no
12. Chemical sensitivities
yes
no
13. Serious sleep issues – insomnia, non obstructive sleep apnea, disturbance of sleep-wake cycle where it is completely imbalanced.
yes
no
14. Nerve pains
yes
no
15. Impotence
yes
no
16. Odd ticks and spasms, and seizure like events
yes
no
17 Night Sweats
yes
no
18. Fibromyalgia
yes
no
19. Hallucinations
yes
no
20. Memory changes – complete loss of words or names
yes
no
21. Hormonal alterations
yes
no
1. Daily medications of sinus sprays, Nasonex
yes
no
2. History of CIRS
yes
no
3. History of Lyme
yes
no
4. Positive MARCoNS
yes
no
5. Ataxia – difficulty walking
yes
no
6. Confusion
yes
no
7. Dementia
yes
no
8. Memory loss
yes
no
9. Tremors
yes
no
10. Sarcoidosis
yes
no
11. Uncontrolled asthma
yes
no
12. Recurring Pneumonia
yes
no
13. Clotting disorders
yes
no
14. Vomiting
yes
no
15. Kidney Disease
yes
no
16. Infertility
yes
no
17. Mast Cell activation syndrome
yes
no
Paragraph
This tool is a clinical assessment tool and is not used to diagnose or treat disease. The above symptoms have been reported in mould and mycotoxin exposed individuals by mould practitioners and research studies. If you have these symptoms it does not mean you necessarily have mould illness.
Text
If you are human, leave this field blank.
Submit
Δ
