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?
