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Table C: Environmental Quiestionnaire
(For Patients with Sentinel Conditions, Symptoms that Vary by Environment, or a history of Recurrent Moisture Incursion)
About Hour Home:
Do you have a central humidifier or air conditioner? Yes: No:
If yes, is the system cleaned infrequently? Yes: No:
Do you have room humidifiers or air conditioners? Yes: No:
If yes, is the system cleaned infrequently? Yes: No:
Is there wall to wall carpet in your bedroom? Yes: No:
Do you regularly see mold on tiles, ceilings, walls, or floors in your bathroom (other thank occansionally on the shower curtain or tub enclosure?) Yes: No:
Do you see mold in your basement on walls, ceilings, or floors? Yes: No:
Do you usually smell a musty odor anywhere in your home? Yes: No:
Does your roof leak? Yes: No:
If yes, how often?
Does your plumbing in your kitchen or bathroom leak? Yes: No:
If yes, how often?
Are there wet spots anywher in your home, including your basement? Yes: No:
Do you often see condensation (fog) on the inside of windos and/or on cold inside surfaces? Yes: No:
Enviromental Tobacco Smoke*
How many people who live in your home, or visit it regularly, smoke on a daily basis? Adults:
  Children: