|
It is very important to ask about all environments in which a child with asthma may be spending significant amounts of time,
including all residences where the child sleeps or spends time, such as the home of a relative, schools, daycare, camp, and college
dorms (for 17 - 18 year olds). Ask the questions in the box first. Ask additional questions if indicated.
Dust Mites
- Have you noticed whether dust exposure makes your child's asthma worse?
Yes [ ] No [ ] Not sure [ ]
Have you used any means for dust mite control? Which ones?____
Yes [ ] No [ ] Not sure [ ]
Additional Questions:
- Do you know that dust exposure can trigger asthma symptoms?_____
- Do you live in a house or an apartment? __________
- If you live in a house, how old is it? __________
- What type of floor coverings are in your house? _______________________________________
- Is there carpet in your child's bedroom? __________
- Do you have a HEPA vacuum cleaner? __________
- Have you tried anything to decrease dust mite exposure?__________________________
- Have you ever heard of putting special coverings on a pillow or mattress to decrease dust mite exposure? __________
- Are you currently using a mattress or pillow covering on your child's bed? __________
- How often do you wash your child's bed linens? __________
- Do you wash them in hot, warm, or cold water? __________
- Are there stuffed animals in your child's room/bed? __________
- Do you use other ways to decrease dust mite exposure? __________
Animal Allergens
- Do you have any furry pets?
Yes [ ] No [ ] Not sure [ ]
Have you seen rats or mice in the home?
Yes [ ] No [ ] Not sure [ ]
Additional Questions:
- What type of furry pet(s) do you have? (and how many of each) ___________________________________________________
- Is it a
- strictly indoor pet? __________
- outdoor? __________
- indoor/outdoor? __________
- How often do you wash your pet? __________
- How long have you had your pet (s)? __________________________
- Has your child's asthma become worse since having the pet? _______
- Has your child's asthma become better since moving the pet outside?
________________________________________________________
- Have you noticed any rodents indoors or outside your home (rats, mice)?
Yes [ ] No [ ] Not sure [ ]
Cockroach Allergen
- Have you seen cockroaches in your home on a regular basis? (i.e., weekly or daily)
Yes [ ] No [ ] Not sure [ ]
Additional Questions:
- Approximately how many cockroaches do you see in your home per day? __________
- Do you see evidence of cockroach droppings?
Yes [ ] No [ ] Not sure [ ]
- How do you get rid of the cockroaches? ____________________
Mold/Mildew
- Do you see or smell mold/mildew in your home?
Yes [ ] No [ ] Not sure [ ]
- Is there evidence of water damage in your home?
Yes [ ] No [ ] Not sure [ ]
- Do you use a humidifier or swamp cooler?
Yes [ ] No [ ] Not sure [ ]
Additional Questions:
- Where do you see mold growth in your home?
Attic ____________ Garage _________
Basement _________ Laundry room _________
Bathroom ________ Other _________
Bedroom __________
- How large an area is the mold growth? _________________________
- Do you have problems with moisture or leaks in your home?
Yes [ ] No [ ] Not sure [ ]
- Do you frequently have condensation on your windows?
Yes [ ] No [ ] Not sure [ ]
- Do you have either of the following in your home:
- Humidifier? __________
- Evaporative-type air conditioner ("swamp cooler")? __________
- How often is it cleaned? ___________________________
- Have you tried using something to decrease the humidity in your home? _________________________________________
Environmental Tobacco Smoke
- Do any family members smoke?
Yes [ ] No [ ] Not sure [ ]
- Does this person(s) have an interest or desire to quit?
Yes [ ] No [ ] Not sure [ ]
- Does your child/teenager smoke?
Yes [ ] No [ ] Not sure [ ]
- How many cigarettes per day? ______
- Does he/she (they) smoke in the house? ______
Outside? _____ Both inside and outside? ______ In the car?
Additional Questions:
- Do you have a smoking ban in the household?_______________
- Does anyone smoke in daycare or other childcare setting where the child stays? ______
- Does anyone who spends time at your house smoke? (friends, neighbors, relatives?) __________
- Describe the circumstances when your child may be exposed to smoke?_________________
Air Pollution
- Have you had new carpets, paint, or other changes made to your house in the past year?
Yes [ ] No [ ] Not sure [ ]
- Does your child or another family member have a hobby that uses toxic materials?
Yes [ ] No [ ] Not sure [ ]
- Has outdoor air pollution ever worsened your child's asthma?
Yes [ ] No [ ] Not sure [ ]
- Does your child play outdoors when an Air Quality Alert (i.e., ozone, particulate) is issued?
Yes [ ] No [ ] Not sure [ ]
- Do you use a wood burning fireplace or stove?
Yes [ ] No [ ] Not sure [ ]
- Do you use unvented appliances such as a gas stove for heating your home?
Yes [ ] No [ ] Not sure [ ]
Additional Questions:
Indoor Air Pollution Questions
- Does anyone in your house use strong-smelling perfumes, scented candles, hairsprays, or other aerosol substances?
__________
- Do you live in a home that was built in the past 1-2 years?
Yes [ ] No [ ] Not sure [ ]
- If you recently made changes to your house-installed new carpets, painted, or other changes - how long ago was that?
___________________
- Was there a change in your child's asthma symptoms after moving to a new house or having the work mentioned above done in your
home?
Yes [ ] No [ ] Not sure [ ]
- Do you ever notice a chemical type smell in your home?
Yes [ ] No [ ] Not sure [ ]
- If you have a wood burning fireplace or stove, how many times per month in the winter do you use it? __________
- Do you use an unvented appliance such as a gas stove for heating your home?
Outdoor Air Pollution Questions
- Do you live within a half mile of a major roadway or highway?
Yes [ ] No [ ] Not sure [ ]
- An area where trucks or other vehicles idle?
Yes [ ] No [ ] Not sure [ ]
- A major industry with smokestacks?
Yes [ ] No [ ] Not sure [ ]
- Is residential or agricultural burning a problem where you live?
Yes [ ] No [ ] Not sure [ ]
|
