Mold Illness Questionnaire

GENERAL

Fatigue that doesn’t otherwise make sense Trouble sleeping Worse after eating Worse after exercise Increased thirst Stubborn weight gain Anemia

SENSITIVITY

Bothered by tags and seams on clothing Chemical sensitivities Sensitive to light, sound, or touch

HEAD/MIND

Slowed thinking or brain fog Unsettled feeling, unquieted mind,overwhelm Headaches Dizziness, vertigo, or drunken feeling Unexplained mood changes, anxiety, or depression

EENT

Allergies/hay fever year-round Eye irritation Dark circles under eyes Floaters in your vision Vision blurry, frequently changes, or difficulty reading Sneezing or persistent runny nose Acute sense of smell for mold Recent sinusitis Ears feel plugged or clogged Itchy or sore ear canals Sores in the mouth Post-nasal drip or frequent throat clearing Chronically sore throat Coated tongue

RESPIRATORY

Easily irritated lungs Episodic cough Shortness of breath, air hunger, or yawn/sigh often

CARDIOVASCULAR

Easy bruising Heart palpitations Lower extremity edema Protruding veins on limb

DIGESTIVE

Nausea Bloated abdomen or flatulence Unexplained change in digestion/bowels Recent change in appetite Crave carbs, sweets, or alcohol

GENITOURINARY

Overactive bladder Bladder infections

SKIN

Skin rash, redness or flushing

IMMUNE

Frequent infections or delayed recovery from colds

MUSCULOSKELETAL

Increased body pain