Environmental Home Risk Assessment

Your Symptoms

*Check All That Apply

Which of these symptoms
do you experience?

Fatigue or low energy Brain fog Respiratory issues Reoccurring Illnesses Chronic Pain Headaches Sleep problems Inflammation Digestive problems Skin issues Allergies Anxiety

Symptom Patterns

*Check All That Apply

Have you noticed any
of these patterns?

Feel better when away from home Symptoms improve when outside Symptoms are worse in certain rooms Symptoms worsen after it rains Morning symptoms are more intense Symptoms change with the seasons You have trouble falling asleep, or staying asleep None of these currently apply to me

Steps You've Taken

*Check All That Apply

What steps have you
already tried?

Consulted multiple doctors Remediation and/or clean-up efforts Tested your air quality before Tried medications Had blood tests Purchased air purifiers or filters Used a dehumidifier Changed your diet or tried supplements

Your Home Environment

Do any of these apply
to your home?

When was your home built? *Required

Before 2000 2000 or after

*Check All That Apply

Visible mold History of water damage Musty odors Attached garage Recent painting and/or renovations More than 25% of your home is carpeted One or more pets More than one (1) person living in the home

Chemical & VOC Exposure

*Check All That Apply

Which of these apply
to your home?

New carpet, furniture, or flooring installed in the last 3 years Noticeable chemical, paint, or solvent smell indoors Pesticides or herbicides used in or around the home Regularly use air fresheners, scented candles or other products to make my air smell better Park one or more cars in my attached garage I store gasoline, lawnmower, or chemicals in my attached garage Do you have any cans of paint stored anywhere in the home? Recent painting, refinishing, or renovation within the last 2 years I often have my clothes professionally Dry-Cleaned Have found a water leak/water damage previously under my kitchen or bathroom sink/cabinet There is a musty, moldy smell in my washing machine, or laundry room I have had my home treated for mice, ants, or bats None of these apply to my home

Your Health Journey

*Check All That Apply

Which of these describe
your health experience?

Seen 2 or more doctors or specialists Symptoms are getting worse over time No clear diagnosis despite testing Medications haven't fully resolved symptoms Symptoms have lasted 6 months or more Been told symptoms may be stress or anxiety I've developed more or new allergies since living in my current home Tried alternative or functional medicine

Your Household

*Check All That Apply

Which of these describe
your household situation?

I am the only one experiencing ongoing health symptoms Others in my home share similar health symptoms Someone in my home has a chronic illness or compromised immune system My pet(s) have unexplained health issues

Structure & Ventilation

*Check All That Apply

Which of these apply to
your home's history and structure?

Home has had a flood, or water damage now, or in the past Water damage was repaired cosmetically without professional remediation Furnace/Air Conditioning HVAC ductwork has never been professionally inspected or cleaned Have you ever had water come into the home from outside? One or more rooms feel stuffy, stale, or have noticeably different air quality Recurring condensation on windows, walls, or pipes Home built before 1980 (asbestos, lead paint, and formaldehyde-based materials common) Attached garage with a direct door into living space

Outdoor Environment

*Check All That Apply

Which of these describe
your home's surroundings?

Within 1 mile of a major highway, freeway, or high-traffic road Near industrial facilities, factories, or manufacturing plants Near agricultural land, farms, or areas with pesticide use Area has experienced wildfire smoke or heavy air quality events Located in a heavily populated city area Located in a high-humidity or flood-prone region You live near Wi-Fi, or electrical power lines, or towers Suburban or rural area with no industrial or agricultural proximity

Your Living Patterns

*Check All That Apply

Which of these describe
how you use your home?

Work from home full-time or most of the week Home was unoccupied or closed up for an extended period before moving in? Windows are rarely or never opened Moved into this home within the last 2 years Spend the majority of your waking hours at home Symptoms began or worsened after moving into this home Consistently sleep poorly at home but better elsewhere

Current Air Management

*Check All That Apply

Which of these describe
your home's air management?

No air filtration system of any kind in the home I change my furnace/air conditioning filter at least every 3 months or sooner No humidity control or monitoring in the home Indoor humidity regularly feels high or sticky Use a portable air purifier but unsure if it's effective Bathroom or kitchen exhaust fans rarely or never used It seems like I have more dust in my home, and on surfaces than what I should have I have a UV light, or professional grade air purifier installed on my furnace/air conditioning HVAC system

Previous Testing

*Check All That Apply

What testing or inspections
have you had done?

Home has never been tested for air quality Only had a basic mold spore test — not a full air quality assessment Testing was done in only one or two rooms, not the whole home Had remediation done but no post-clearance test to confirm it worked Inspector said nothing was found but symptoms continued Received test results but wasn't sure what they meant Have had a professional air quality test completed but only for mold I have had a comprehensive air quality test for mold, chemicals, radon and more — and they identified what the problems were, where they were, and why

Which of these symptomsdo you experience?

Have you noticed anyof these patterns?

What steps have youalready tried?

Do any of these applyto your home?

Which of these applyto your home?

Which of these describeyour health experience?

Which of these describeyour household situation?

Which of these apply toyour home's history and structure?

Which of these describeyour home's surroundings?

Which of these describehow you use your home?

Which of these describeyour home's air management?

What testing or inspectionshave you had done?

Your Environmental HomeRisk Assessment Results

Which of these symptoms
do you experience?

Have you noticed any
of these patterns?

What steps have you
already tried?

Do any of these apply
to your home?

Which of these apply
to your home?

Which of these describe
your health experience?

Which of these describe
your household situation?

Which of these apply to
your home's history and structure?

Which of these describe
your home's surroundings?

Which of these describe
how you use your home?

Which of these describe
your home's air management?

What testing or inspections
have you had done?

Your Environmental Home
Risk Assessment Results