Environmental & Mycotoxin Intake Form

01Personal Details

Full name

Date of birth

Email

Date completing this form

Which test(s) are you completing?

MycoTOX (mould / mycotoxins) EnviroTOX Complete (environmental chemicals) Both

02Mould & Water Damage Exposure

Primary section for MycoTOX — skip if EnviroTOX only

Have you ever lived or worked in a building with known water damage, flooding, or visible mould?

Yes — current building Yes — past building Yes — both past and current No — not to my knowledge Unsure

Where was / is the water damage or mould? (tick all that apply)

How long were you exposed to the affected environment?

Did your symptoms improve when away from the affected building for extended periods (holidays, travel)?

Yes — clearly better away Somewhat No difference Not noticed / not tested

Previous mould remediation or air testing carried out?

Yes — mould confirmed and remediated Yes — ongoing issue No

Additional mould / water damage details

03Chemical & Environmental Exposure

Primary section for EnviroTOX — relevant to both tests

04Symptom Pattern

Rate each: 0 = absent, 1 = mild/occasional, 2 = significant/frequent

Fatigue (not relieved by rest)

Brain fog / cognitive impairment

Word-finding difficulty

Memory problems

Headaches

Sinus congestion / respiratory symptoms

Chemical sensitivity / smell sensitivity

Immune dysregulation / frequent infections

Gut / digestive symptoms

Skin reactions / rashes

Joint or muscle pain

Mood changes / anxiety / depression

Tremor / neurological symptoms

Visual disturbances

When did symptoms begin / worsen relative to an identified exposure?

Previous detoxification attempts (saunas, binders, chelation, etc.)

05Previous Testing & Medical Context

Intake form submitted