Agency for Toxic Substances and Disease Registry
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Family Name: _____________________________ | ||||||
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___________________________________________________________________ |
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Housing | ||||||
Type of Housing? _________________________ | ||||||
How old? _______________________________ | ||||||
Condition? ______________________________ | ||||||
Ownership? | ||||||
Rental _____ | Owner-occupied _____ | Public housing _____ | ||||
Renovation/repairs occurring? | ||||||
_____ Yes | _____ No | |||||
Describe: ____________________________________________________ | ||||||
Existing rodents/insects? | ||||||
_____ Yes | _____ No | |||||
Describe: ____________________________________________________ | ||||||
Existence of molds/fungi? | ||||||
_____ Yes | _____ No | |||||
Describe: ____________________________________________________ | ||||||
What source of drinking water? | ||||||
Describe: ____________________________________________________ | ||||||
Heating Source | ||||||
Uses gas stoves/ovens for heating? | ||||||
_____ Yes | _____ No | |||||
Adequate ventilation? | ||||||
_____ Yes | _____ No | |||||
Uses fireplaces/woodburning stoves? | ||||||
_____ Yes | _____ No | |||||
What is burned? _______________________________________________ | ||||||
Wood smell indoors? | ||||||
_____ Yes | _____ No | |||||
Evidence of smoke/soot? | ||||||
_____ Yes | _____ No | |||||
Uses kerosene heaters? | ||||||
_____ Yes | _____ No | |||||
Environmental Tobacco Smoke | ||||||
Household members smoke? | ||||||
_____ Yes | _____ No | |||||
Regular visitors smoke? | ||||||
_____ Yes | _____ No | |||||
Smoking allowed in car? | ||||||
_____ Yes | _____ No | |||||
Indoor Air Pollution-Formaldehyde and Asbestos | ||||||
Sources of formaldehyde? (particle board, urea in foam insulation, other) | ||||||
_____ Yes | _____ No | |||||
Describe: ____________________________________________________ | ||||||
Potential asbestos hazards? (friable pipe/boiler insulation, old vinyl linoleum, wall board repair, home renovation or repairs) | ||||||
_____ Yes | _____ No | |||||
Describe: ____________________________________________________ | ||||||
Air Pollution-Toxic Organic Hydrocarbons | ||||||
Uses cleaners/polishers/air fresheners/disinfectants | ||||||
_____ Yes | _____ No | |||||
Uses glues/solvents/varnishes/building materials? | ||||||
_____ Yes | _____ No | |||||
Where are these materials stored? ____________________________________ | ||||||
Pest/Mold/Fungi Control | ||||||
Home garden | ||||||
_____ Yes | _____ No | |||||
Use of pesticides outdoors | ||||||
_____ Yes | _____ No | |||||
Evidence of rodents/insects | ||||||
_____ Yes | _____ No | |||||
Use of pesticides indoors? | ||||||
_____ Yes | _____ No | |||||
Use of pesticides on children? | ||||||
_____ Yes | _____ No | |||||
What type? __________________________________________________ | ||||||
Use of pesticides on pets? | ||||||
_____ Yes | _____ No | |||||
What type? _________________________________________________ | ||||||
Is re-entry after pesticide use according to instructions? | ||||||
_____ Yes | _____ No | |||||
Evidence of molds/fungi? Yes No | ||||||
_____ Yes | _____ No | |||||
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*Adapted from Balk et al. (1999). |