Immune Response and Mold Sensitivity Evaluation

This evaluation is a part of your provider’s assessment of your health. It looks at a key risk factor that may be a contributing or causal factor in your health condition.

Fungal Infections are most often triggered by a genetic trait inherent in at least sixteen percent of the population. The reaction is commonly known as a fungal allergy. Symptom can be as mild as sinus congestion, headaches, and polyps or severe as auto immune disease.

Evaluation for fungal allergy helps you to understand the symptoms and risk behaviors common to mold related disease. This evaluation is 25 questions long and will take approximately 5 minutes to complete. You will receive an email that gives you the severity of your results and a protocol for treating your symptoms. We recommend you discuss the results with your provider.

Your email address:

First and Last Name:

Submit

Section 1: Sinus History

1. How many sinus infections have you had in the past year?

0

1

2

3

4

5+

2. How many times a month do you have sinus headaches (not migraines)?

0

1

2

3

4

5+

3. How many times have you taken antibiotics in the last year?

0

1

2

3

4

5+

4. Have you had aspirin allergy?

No

Yes

5. Do you have loss of smell?

No

Yes

6. Do you have nasal airway obstruction?

No blockage

Occasionally

At night your nose feels stopped up

Fairly frequently

Completely blocked on one or both sides all the time

7. Do you have postnasal drip?

None

Rarely

Occasionally

Frequently

Most of the time

8. Do you have allergies (non-food)?

Yes

No

9. How many sinus surgeries have you had?

012345

Section 2: Your Environment

10. Has the furnace or air conditioner location in your home ever been damp?

No

Yes

11. Is the heater or air conditioner located in a dirt crawl space?

No

Yes

12. Is your crawl space damp?

No

Yes

13. Is the heater located in the attic with blown-in insulation?

No

Yes

14. Do you have a humidifier in the central furnace?

No

Yes

15. Have you had a leak or flood anywhere in your home?

No

Yes

16. Do you ever notice a musty smell in the house?

No

Yes

17. Have you noticed any mold in the house (other than the bathroom shower/tub)?

No

Yes

18. Do you feel better (physically) away from home

No

Yes

19. Do you feel better (physically) away from the office?

No

Yes

20. Do you or your co-workers feel bad at the office?

No

Yes

21. Do you feel better if you go to the beach or other clean air space?

No

Yes

22. Do you have pets in the home?

No

Yes

23. Do you sleep with your pets?

No

Yes

Section 3: Additional History

24. Do you experience fatigue or tiredness regularly?
Rate your level of fatigue:  0=can walk 5 miles        10=can't get out of bed

012345678910

25. Do you have any of the following? (Check all that apply)

Abdominal pain

Memory loss and/or problems concentrating

Other neurocognitive dysfunction

Food Allergies

Attention Deficit Disorder (ADD)

Blurred vision

Constipation

Chest tightness

Diabetes

Insomnia

Diarrhea

Numbness/tingling

Bloating and/or gas

Laryngitis

Stomach Pain

Anxiety, depression, or irritability?

Gut Problems ( Enteropathy)

Leaky Gut Syndrome

Gluten Sensitivity

Skin rashes

Psoriasis

Eczema

Loss of protein in gut

Hives

Gastritis (Stomach inflammation)

Urticaria (itching)

Cloitis (bowel inflammation)

Tremors/seizures

Hyperactivity

Shortness of breath

Hypoglycemia (low blood sugar)

Cancer

Interstitial cystitis (bladder inflammation)

Lymphoma

Migraines

Leukemia

Obesity

Lupus

Muscle and/or joint pain/fibromyalgia

Esophageal acid reflux

Weakness

Asthma

Bronchitis

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By inputting your email you agree that you have read the disclaimer below. You will receive a copy of your results by email shortly. We may also send an email newsletter, and you can opt out any time.

DISCLAIMER: The evaluation is designed to assist your healthcare professional in diagnosis of your symptoms as they relate mold. The contents of this Immune Response and Mold Sensitivity Evaluation is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. This is not to substitute for a thorough evaluation by one’s own doctor. Never disregard professional medical advice or delay in seeking it because of something you have read in this evaluation or on any of the other Micro Balance Health Products websites.

Micro Balance Health Products does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on this website. Reliance on any information provided by Micro Balance Health Products or its employees, or others appearing on the website at the invitation of Micro Balance Health Products is solely at your own risk. If you are sensitive to, or have any negative symptom from, any product on this site, discontinue it immediately and consult your own physician if symptoms persist.