Client Pre-Consultation Questionnaire

Please complete this questionnaire as thoroughly as you are comfortable. Your answers will help provide a clearer picture of your health history, environmental exposures, current concerns, and where you may be in your CIRS journey.

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Name

This field is for validation purposes and should be left unchanged.

Contact Information

Full Name*

Date of Birth*

Month

Day

Year

Email Address*

Phone Number*

City/State*

Preferred Method of Contact

About You

What brings you to CIRS Healing & Consulting LLC?

What are your three biggest concerns right now?

How long have you been experiencing symptoms?

Have your symptoms affected your ability to work, attend school, care for your family, exercise, socialize, or complete normal daily activities?

Yes

If yes, please explain.

CIRS History

Have you been diagnosed with Chronic Inflammatory Response Syndrome (CIRS)?

Yes

Suspected

Currently being evaluated

If diagnosed, who diagnosed you and approximately when?

Are you currently working with a physician or other licensed healthcare provider for CIRS or a related condition?

Yes

Have you previously worked with a Shoemaker Protocol practitioner?

Yes

Unsure

Have you completed any CIRS-related laboratory testing? Check all that apply.

HLA-DR/DQ

MSH

TGF-beta 1

C4a

MMP-9

VEGF

ADH/Osmolality

ACTH/Cortisol

MARCoNS

VCS Testing

NeuroQuant MRI

GENIE

Other

None

Please list any significant results you would like us to know about.

Current Symptoms

Which symptoms are you currently experiencing? Check all that apply.

Fatigue

Brain fog

Memory or concentration difficulties

Headaches

Dizziness or lightheadedness

Muscle aches

Joint pain

Weakness

Numbness or tingling

Sleep disturbances

Mood changes

Anxiety

Temperature regulation problems

Excessive thirst

Frequent urination

Sinus or nasal symptoms

Shortness of breath or respiratory symptoms

Digestive symptoms

Abdominal discomfort or bloating

Food sensitivities

Chemical or fragrance sensitivities

Light sensitivity

Sound sensitivity

Visual changes

Skin symptoms or rashes

Unusual sweating

Static shocks

Metallic taste

Appetite changes

Weight changes

Other

Please describe the symptoms that interfere with your life the most.

On a scale of 1–10, how would you rate your current overall symptom burden?

1 = Minimal symptoms | 10 = Extremely severe symptoms

Mold & Environmental Exposure History

Do you currently live or work in a building where you suspect mold, water damage, or poor indoor air quality?

Yes

Unsure

Have you previously lived or worked in a water-damaged or mold-contaminated building?

Yes

Unsure

Have you experienced any of the following?

Roof leak

Plumbing leak

Basement water intrusion

Flooding

Foundation moisture

HVAC contamination

Visible mold

Musty or unusual odors

Condensation problems

High indoor humidity

Sewage backup

Other known water damage

Approximately how long do you believe you were exposed?

Are you still being exposed to the environment of concern?

Yes

Unsure

Have you had environmental testing performed?

ERMI

HERTSMI-2

Air sampling

Surface sampling

Mold inspection

Mold detection canine inspection

Moisture investigation

Other

No testing

If testing was performed, please briefly describe the findings.

Other Potential Exposures

Have you had known or suspected exposure to any of the following?

Tick-borne illness

Lyme disease

Dinoflagellates

Cyanobacteria

Actinomycetes

Endotoxins

VOCs

Pesticides

Heavy metals

Chemical exposures

Wildfire smoke

Other environmental exposures

Unsure

Related Health History

Have you been diagnosed with or evaluated for any of the following?

Lyme disease or other tick-borne illness

Mast cell activation syndrome (MCAS)

POTS or dysautonomia

SIBO

Chronic sinus problems

MARCoNS

Autoimmune condition

Thyroid condition

Chronic fatigue

Fibromyalgia

Multiple chemical sensitivity

Long COVID

Other chronic health condition

Please list any other diagnoses or significant health conditions you feel are relevant

Current Treatment & Support

Are you currently taking any prescription medications, binders, supplements, or other therapies related to CIRS or environmental illness?

Yes

If yes, please list them.

Have you previously used any of the following?

Cholestyramine

Welchol/colesevelam

Other binders

MARCoNS treatment

BEG or other prescription nasal treatment

VIP

Low-mold diet

Low-histamine diet

Environmental remediation

Relocation from a water-damaged building

Other

Do you currently have a physician or licensed healthcare professional overseeing your medical treatment?

Yes

Environmental Decisions

Are you currently trying to determine whether your home or workplace may be contributing to your symptoms?

Yes

Unsure

Are you considering remediation, moving, or having additional environmental testing performed?

Yes

Unsure

What environmental questions are you hoping to better understand?

Your Goals

What would you most like help navigating? Check all that apply.

Understanding CIRS

Understanding the Shoemaker Protocol

Organizing my CIRS journey

Understanding terminology and testing

Preparing questions for my healthcare providers

Understanding environmental testing options

Navigating mold exposure concerns

Finding appropriate professional resources

Organizing laboratory results and records

Understanding where I am in the CIRS process

Creating an organized list of questions and priorities

General CIRS education and support

Other

What would make your consultation feel successful to you?

Additional Information

Is there anything about your health history, environmental history, current situation, or CIRS journey that you feel is important for me to know before we meet?

Important Disclaimer & Acknowledgment

CIRS Healing & Consulting LLC provides educational information, health coaching, navigation, and support services. These services are not a substitute for medical care and do not constitute medical diagnosis, treatment, prescribing, or medical advice.

CIRS Healing & Consulting LLC does not diagnose medical conditions, prescribe medications, order medical treatment, or replace the care of a licensed physician or other qualified healthcare professional.

Information discussed during consultations is intended to help clients better understand CIRS-related concepts, organize information, prepare questions for their healthcare providers, understand available resources, and navigate their individual journey.

Environmental information provided through consulting services should not be considered a substitute for professional environmental assessment, remediation advice, medical clearance, or other services requiring appropriately licensed or qualified professionals.

Always consult your physician or other qualified healthcare provider regarding medical symptoms, diagnoses, medications, supplements, laboratory testing, treatment decisions, or changes to your healthcare plan.

By submitting this questionnaire, I acknowledge that I understand the educational and consulting nature of the services provided by CIRS Healing & Consulting LLC.

Consent

I have read and understand the above disclaimer and acknowledgment.

Client Name:

Date:

Month

Day

Year