Case Evaluation Initial Contact Name Date E-mail Referred by Phone Main concern Health symptoms Number of residents How long at this residence Onset of symptoms (date) Residence Setting House Duplex Rent Agricultural Subdivision Condo Apartment Own City/Town Waterfront Stories Square footage Attached garage Yes No Year of construction Type of HVAC Ductwork present Yes No Visible mold Description/location of mold Yes No Water intrusion events Remediation by homeowner Remediation by contractor Documentation Investigation report Diagram Contractor scope of work Photos History/timeline List of questions Symptom documentation Sample data Medical documentation ERMI Air Surface Additional comments
Case Evaluation Initial Contact Name Date E-mail Referred by Phone Main concern Health symptoms Number of residents How long at this residence Onset of symptoms (date) Residence House Duplex Condo Apartment Rent Own Setting Agricultural Subdivision City/Town Waterfront Stories Square footage Attached garage Yes No Year of construction Type of HVAC Ductwork present Yes No Visible mold Yes No Description/location of mold Water intrusion events Remediation by homeowner Remediation by contractor Documentation Investigation report Diagram Contractor scope of work Photos History/timeline List of questions Symptom documentation Sample data Medical documentation ERMI Air Surface Additional comments