Clinician/IEP Communications Forms

The information in the forms below can be copied into an email or printed out and filled in.

The goal is to help clinicians, Indoor Environmental Professionals (IEPs), and patients communicate more effectively.

We hope this format will help all parties better understand the circumstances of the patient/home and create a framework for discussions, responsibilities, and decision making.

FORM 1: For clinicians to effectively communicate to IEPs, about a new patient/client:

1) In terms of stratification, this patient:
-is currently in a stage of:
          a) initial/early evaluation
          b) ongoing treatment
         c) meaningful improvement, status post significant treatment over time
-in my experience, is symptomatically of:
          a) high severity/acuity
          b) moderate severity/acuity
          c) low severity/acuity 
2) Diagnostically, this patient has:
-concerns for CIRS/mycotoxin illness, based on
          a) symptoms of ________________________________________________________________________, and/or
          b) lab results of ________________________________________________________________________
-other conditions concomitant to CIRS/mycotoxin illness, with
          a) suspicions for _______________________________________________________________________, and/or
          b) diagnoses of ________________________________________________________________________
3) My respectful request for you, as an IEP, on behalf of my patient, is:
          a) to look for sources and degrees of mold and other microbes
          b) to assess for non-microbial exposures: a) EMFs, b) VOCs, c) other _____________________________
          c) other: ______________________
     for the purpose of:
          a) an initial evaluation to determine if this patient is currently exposed to such contaminants/toxins
          b) a follow up evaluation to determine if this patient is still exposed to such contaminants/toxins (given whatever clean up/remediation work that has been performed to date)

FORM 2: For IEPs to effectively communicate back to clinicians, about a client/patient’s environmental assessment:

1) In terms of stratification, this building:
-was assessed for this client’s/family’s health as:
          a) an initial evaluation (boots-on-the-ground/site visit)
          b) an initial evaluation (virtual consultation)
          c) a follow-up evaluation, in the midst of clean-up/remediation  (boots-on-the-ground/site visit)
          d) post- clean-up/remediation  (boots-on-the-ground/site visit)
          e) a review of already collected findings/data (2nd opinion)
-in my experience, is assessed as:
          a) highly contaminated/toxic
          b) moderately contaminated/toxic
          c) minimally contaminated/toxic
          d) normal or otherwise a not indicating a contaminated/toxic environment
2) Diagnostically, this building has:
-evidence for mold/bacterial contamination/toxins, based on
          a) visual findings of ________________________________________________________________________, and/or
          b) quantified results of ______________________________________________________________________
-other conditions concomitant to mold/bacterial contamination/toxins, with
          a) suspicions for _______________________________________________________________________, and/or
          b) confirmed findings of _______________________________________________________________________
3) (If #2 is positive): The areas of greatest concern (potential to cause exposure) and priority to me, in rank order of intensity as a source of microbial toxicity, are (room, structure, problem):
          a) _____________________________________________________________ (ie, kitchen, east lower corner of wall, superficial visual mold with water damaged wall thickness)
          b)  _____________________________________________________________
          c)  _____________________________________________________________
          d)  _____________________________________________________________
          e)  _____________________________________________________________
4) In response to your request of me, as an IEP, on behalf of your patient, my conclusion is/conclusions are:
          a) your concern for this building as a current and active source of mold and/or other microbes is highly, moderately, minimally, or uncertainly supported
          b) this building is found to be contaminated with non-microbial toxins: a) EMFs, b) VOCs, c) other _____________________________, at a high, moderate, minimal, or uncertain level
          c) other: ______________________________