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.
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? ______
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? __________________
Do you ever notice a chemical type smell in your home?_________________
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 ½ mile of / a major roadway or highway? ______
an area where trucks or other vehicles idle? _____
a major industry with smokestacks? ________
Is residential or agricultural burning a problem where you live? ______________ /