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Table D: Current Symptoms - History and Relationship to Home, Work, or School
(For Patients in Which a Potential Exposure to Mold Exists)
Symptoms that may be related to mold.

Please put a checkmark for your response:
Are you Troubled by: How is it at home? How is it at work or school? Comments:
Wheezing or whistling in your chest?
Yes: No: Better Worse Same Better Worse Same
Waking up first thing in the morning with a feeling of tightness in your chest?
Yes: No: Better Worse Same Better Worse Same
Waking up during the night with shortness of breath?
Yes: No: Better Worse Same Better Worse Same
Shortness of breath when you are not doing anything strenuous?
Yes: No: Better Worse Same Better Worse Same
Waking up during the night by an attack of coughing?
Yes: No: Better Worse Same Better Worse Same
Chest tightness when you were in a dusty part of the house or with animals (for instance dogs, cats, or horses) or near pillows (including quilts)?
Yes: No: Better Worse Same Better Worse Same
Chills or Fevers?
Yes: No: Better Worse Same Better Worse Same
Aching all over?
Yes: No: Better Worse Same Better Worse Same
Runny, blocked, or stuffy nose?
Yes: No: Better Worse Same Better Worse Same
Headaches?
Yes: No: Better Worse Same Better Worse Same
Extreme or unusual lethargy and/or tiredness?
Yes: No: Better Worse Same Better Worse Same
Frequent sinus congestion?
Yes: No: Better Worse Same Better Worse Same
Frequent nose bleeds?
Yes: No: Better Worse Same Better Worse Same
Hoarseness?
Yes: No: Better Worse Same Better Worse Same
Feeling of unsteadiness when walking?
Yes: No: Better Worse Same Better Worse Same
Memory loss?
Yes: No: Better Worse Same Better Worse Same
Difficulty recalling names of people you know?
Yes: No: Better Worse Same Better Worse Same
Nausea?
Yes: No: Better Worse Same Better Worse Same
Vomiting?
Yes: No: Better Worse Same Better Worse Same
Diarrhea?
Yes: No: Better Worse Same Better Worse Same
Skin Conditions?
Yes: No: Better Worse Same Better Worse Same