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.

Dust Mites

Additional Questions

• Do you know that dust exposure can trigger asthma symptoms?_____
• Do you live in a house or an apartment? __________
• If you live in a house, how old is it? _______
• What type of floor coverings are in your house? ____________________
• Is there carpet in your child's bedroom? ______
• Do you have a HEPA vacuum cleaner? ______
• Have you tried anything to decrease dust mite exposure?__________________________
• Have you ever heard of putting special coverings on a pillow or mattress to decrease dust mite exposure? ______
• Are you currently using a mattress or pillow covering on your child's bed? _____
• How often do you wash your child's bed linens? ______
• Do you wash them in hot, warm, or cold water? _______
• Are there stuffed animals in your child's room/bed? _______
• Do you use other ways to decrease dust mite exposure? _____

Animal Allergens

Additional Questions:

• What type of furry pet(s) do you have? (and how many of each) ____________
• Is it a strictly indoor pet? ______ outdoor? _____ indoor/outdoor? _____
• How often do you wash your pet? ______
• How long have you had your pet (s)? _________________
• Has your child's asthma become worse since having the pet? _______
• Has your child's asthma become better since moving the pet outside? ________
• Have you noticed any rodents indoors or outside your home (rats, mice)?

Cockroach Allergens

Additional Questions:

• Approximately how many cockroaches do you see in your home per day? _____
• Do you see evidence of cockroach droppings? ____________________
• How do you get rid of the cockroaches? ____________________

Mold/Mildew

Additional Questions:

• Where do you see mold growth in your home? Bathroom_____ Bedroom______ Attic _____ Basement _____Garage ______ Laundry room______ Other________
• How large an area is the mold growth? ________________________
• Do you have problems with moisture or leaks in your home? _________
• Do you frequently have condensation on your windows? _________
• Do you have either of the following in your home:
  • humidifier? _______
  • evaporative-type air conditioner (“swamp cooler”)? _______
• How often is it cleaned?_______
• Have you tried using something to decrease the humidity in your home? _________

Environmental Tobacco Smoke

Additional Questions

• Who in the family smokes cigarettes? ___________
  • How many cigarettes per day? ______
  • Does he/she (they) smoke in the house? ______

    Outside? _____ Both inside and outside? ______ In the car? ______

• Do you have a smoking ban in the household?_______________
• Does anyone smoke in daycare or other childcare setting where the child stays? ______
• Does anyone who spends time at your house smoke? (friends, neighbors, relatives?) __________
• Describe the circumstances when your child may be exposed to smoke?_________________

Air Pollution

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? ______________ /