LOCATION
City: State: Zip:
Area Code: 

FAMILY MEMBERS AFFECTED
Age Of Affected Party: Gender of Affected Party: Cigarette Smoker?:
Age Of Affected Party: Gender of Affected Party: Cigarette Smoker?:
Age Of Affected Party: Gender of Affected Party: Cigarette Smoker?:
Age Of Affected Party: Gender of Affected Party: Cigarette Smoker?:
Children?: Please enter their ages:
Pets?: Types: Please enter their ages:
Effects of pets exposure: 

BUILDING INFORMATION
Age of building where exposure occured: Type of Roof: Type of Heat(i.e; forced air:)
Type of Interior Walls: Where did the moisture problem originate: Type of Molds Identified:
Briefly describe the scope of the mold contamination: What was the source of the mold: Have you sustained property damage:
Briefly describe the damage to home or building: Briefly describe damage to personal belongings: Was this issue disclosed to you by your landlord/realtor/Home inspector:
Did your health force you to leave: Did you have to relocate: Type of building (i.e; Home, school, work)
If the exposure was at work what type of facility was it? Homeowner or Condo Association? Do you own or rent?
Are other homes or units effected? Purchase or Lease Date Type of Exterior Siding
Are there zoning issues? Were you evicted for calling for help? Do you feel that the mold could have been prevented?
If so how? 
HEALTH INFORMATION
What Symptoms appeared after exposure: Were your symptoms diagnosed by a physician? What type of physician?
Would you recommend this physician to others? Did you have Blood tests taken for Toxins? What Lab did you use?
What were your results? How long were you sick before getting a diagnosis? Were you mis-diagnosed?
If so what was the diagnosis? Do you have health insurance? If so did they deny any mold related testing?
Were you able to get the tests anyways? Did you call the health department? Did they help?
Have you had a neuro-pysch exam? Was it abnormal? What is your current diagnosis? 
Notifications
Who did you notify? What was their response? Was any action taken to rectify the situation? 
Remediation
What company was called in for testing? What certifications do they hold? Would you recommend this company to others?
What company was called in for remediation? What certifications do they hold? Would you recommend this company to others?
What type of spore collection was used? What was your highest spore count? What type of mold had the highest count?
What chemicals or biocides were used? Was this a covered loss? Please Describe:
Are you still covered under the same insurance? Are there laws in your city/state pertaining to mold? If Yes Please Describe:
Are you still sick after remediation? If Yes Please Describe: Did you move back after remediation? 
INSURANCE
Have you filed an insurance claim? What was their response? Were there any problems(Please describe)? 
LEGAL
Are you involved in a personal injury case as a result of the mold? If so have you secured an attorney?
Has this lawyer represented other mold cases? Has a statute of limitations stopped your lawsuit? 
MISC
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