Products & Services To Save Your Health
Please print this form to fill it out. After it is filled out it can be faxed to 1-509-246-1065
Take A few minutes to fill out the LifeSpan Systems Health Survey. We Will examine the results, and discuss them with you. This survey will help determine if a mold test is appropriate for you. This survey is only a guide. Testing for mold tells what types of mold there are, and what quantities of molds are present. Mold tests can be very expensive and are not always needed. When a building becomes sick from mold, the results can be devastating to the occupants. It can make them extremely sick and can cost thousands of dollars to repair the damage. We understand mold and will help you to avoid the common costly mistakes that are usually made.
Are You Living With Mold? This survey is to determine the possible presence of mold in a building.
Date of Survey Required Your Name Required
Home Number Required E-Mail Required
Address of Sick Building City
State Zip
Your Mailing Address if Different From Above Address;
Street Address City State Zip
What location is this survey for? Example: Home, School, Office, Car.
Mark all the Symptoms that you experience;
Feeling generally crummy or run down? A feeling of being zoned or
drugged?
Itchy or watery eyes? Runny nose?
Sinus congestion? Sore throat?
Lump in the throat or swollen throat? Loss of voice?
Frequent headaches? Pressure behind the eyes?
Blurred vision? Frequent eye infections?
Unusually tired? Deep muscle aches?
Joint aches? Unusual chest pains?
Rapid heart beat? Tightness in the chest?
Stroke like symptoms lasting hours or days? Flu like symptoms?
Unusual vomiting? Acid reflux?
Frequent diarrhea? Unusual nose bleeds?
Coughing up blood? Frequent coughing or sneezing?
Numbness in the tongue or lips? Numbness in the Temples?
Hot tender spots on the scalp? Lumps or sores on the scalp?
Burning rash that leaves scars? Sores that won't heal?
Eczema? Athletes foot?
Swollen lymph glands? Unusual swelling of the hands or feet?
Unusual tooth decay? Unusual hair loss?
Depression? Loss of concentration or inability to think clearly?
Short term memory loss? Long term memory loss?
Inability to sleep at night? Night sweats?
Difficulty breathing at night? Respiratory inflammation?
Frequent ear infections? Frequent sinus infections?
Fluid in the ears? Antibiotics don't seem to help when they should?
Ringing in ears? Fainting?
Heartburn? Convulsions/Seizures?
When are the symptoms most noticeable?
Time of Day : Morning Afternoon Evening Bedtime
All of the above
Time of Year: Winter Spring Summer Fall
Have you been diagnosed with;
AIDS? Amyloidosis?
Arteriosclerosis? Asthma?
Bronchial Pneumonia? Bronchitis?
Cancer? Chemical Sensitivities?
Chrohns Disease? Chronic Fatigue?
Cirrhosis of the Liver? Cushing's Disease?
Diabetes Mellitus? Digestive Disorders? Irritable Bowel Syndrome?
Epstein Barr Virus? Gout?
Hyperactivity Syndrome? Infertility?
Interstitial Cystitis? Kidney Failure?
Kidney Stones? Leukemia?
Lichen Sclerosis? Multiple Sclerosis?
Muscle Disorders? Neurological Disorders?
Pneumonia? Psoriasis?
Rheumatoid Arthritis? Sarcoidosis?
Sleep Apnea? Systemic Lupus?
Vasculitis?
List any Degenerative Diseases not included in this list that you may have;
Has There Ever Been a SIDS Death In Your Home? Yes No
About The Area Being Diagnosed For Mold;
Is the building located next to; Highways or Airports A waste dump site A parking garage Industrial Plants Commercial Business None of the above
Have any recent changes been made to the building (painting, weatherization, remodeling, new furniture, etc.)? Yes No If Yes were there any changes in anyone's health after the improvements ? Yes No
Have you recently acquired new items containing particleboard, paneling, or pressed wood? Yes No
Do you frequently see insects in your building? Yes No
Are insecticides or pesticides frequently applied inside the building? Yes No
Do you currently have pets? Yes No
If you have pets are they allowed in the bedrooms? Yes No
Do you have indoor houseplants? Yes No
If you have an attached garage, do you warm up your car inside it in the winter time? Yes No
Does any member of the building work around animals, furs, feathers, chemicals or dust ? Yes No
Does the building have a carbon monoxide detector? Yes No
Do more than one member of the building have the same or similar symptoms? Yes No
Are any of the members sensitive to smells such as perfume, hair spray or chemicals? Yes No
Has there been any flood, roof leak, broken water pipe, or any other moisture problem in the building? Yes No
Please give details to the water infiltration to the structure
Is there any area that has a foul smell? Yes No Location?
Is there any area that smells like an old building? Yes No Location?
Is there any area that smells like dirty socks, a locker room or dirty laundry? Yes No Location?
Is there any area that has a damp earthy odor? Yes No Location?
Is there any area that has a musty or mildew odor? Yes No Location?
Do your towels get a musty or moldy smell within a week? Yes No
How often do you have to dust to stay dust free?
Do you get dust bunnies on your hard surface floors within a week? Yes No
Have you ever seen mold or mildew in any place in the building? Yes No Location?
Give the location where you have smelled the odor or mildew in the building.
What room is the odor of mold or mildew the strongest?
Existing Buildings;
What is the year built for the sick building?
Is the building on a concrete slab? Yes No
Does the building have a crawlspace? Yes No
Is there a satisfactory moisture barrier in the crawlspace? Yes No
Does the building have a basement? Yes No
Was the concrete foundation properly water sealed? Yes No
Has there been moisture visible at any time in the basement or crawlspace? Yes No
Is there an exhaust fan in the restrooms? Yes No
Kitchen? Yes No Utility Room? Yes No
What method of construction was used?
What kind of siding was used?
Was a moisture barrier building wrap used? Yes No
What type of wrap was used? Tar paper? Tyvek wrap?
Is the attic vented per code? Yes No
Is the crawlspace vented per code? Yes No
Where is the furnace installed?
How is the Building Heated?
Baseboard Heat? Radiant Ceiling Heat? Radiant Floor Heat? Wood Stove? Solar Heat?
Furnace forced air? Gas? Electric? Oil?
Do you have air conditioning? Yes No
Do you have a dehumidifier? Yes No If so where is it located?
Do you have a humidifier? Yes No If so where is it located?
Do you have an electronic air cleaner? Yes No
Do the units you have work automatically and synergistically? Yes No
New Construction;
Date Construction was started?
Describe the method of construction of the walls.
Has there been moisture visible at any time in the crawlspace or basement? Yes No
When the dimensional lumber was delivered was there any mold present on it? Yes No
When the plywood was delivered was there any mold on any of it? Yes No
Did it rain or snow before the floor system was built? Yes No
Did it rain or snow after the framing was built but before the finished roof was installed? Yes No
Did it rain or snow before or while the moisture barrier building wrap was installed? Yes No
If it was raining, snowing or high humidity, was there time given to let the sheathing dry out before installing the house wrap? Yes No
When the building wrap was installed, were there pieces overlapped like roofing? Yes No
Was Tyvek tape used on the joints? Yes No
Did the building wrap create a water tight building at all openings in the framework? (If it rained hard would water be able to get in between the building wrap and the sheathing?) Yes No
After the building wrap was applied did it rain or snow before the windows were installed? Yes No
What type of siding was used?
After the outside of the building was complete was there any time when moisture was allowed to wet any part of the inside of the building? (Plumbers or workers tracking in moisture, or mud from outside.) Yes No
If the building got wet from any cause, was it dried out using any reasonable method, or did continue without drying? (Reasonable methods would include; Period of time for natural drying, mechanical drying using dehumidifiers, etc.) Yes No
Please give details of method used for drying the building.
Is there a known spring or natural water source around the building? Yes No
Is the building on or near a river or lake? Yes No
What is the water table level? Feet Inches
Before the insulation was installed was there any visible mold on any of the building materials?
Walls ? Yes No Attic? Yes No Crawlspace? Yes No
At the time of sheetrock installation what were the weather conditions?
Was a vapor barrier used on the insulation or behind the sheetrock? Yes No
Was heat used to dry the sheetrock and paint in the building? Yes No
How is the building heated?
Baseboard heat? Radiant Ceiling heat? Radiant floor heat?
Wood stove? Solar heat? Forced air furnace?
Gas? Electric? Oil?
Do the units you have work electronically and synergistically? Yes No
Do the windows open? Yes No In What Rooms?
Are there adequate exhaust fans in the restroom? Yes No
Utility Room? Yes No Kitchen? Yes No
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