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