Name: _____________________________	Date Completed:_______________
Address of this home: ________________________________________________
Date moved in: ___________________________
Parents and other adults in the home: _____________________________________ __________________________________________________________________
Current jobs of occupants (including how long in job): ________________________ __________________________________________________________________
1. Do you think you or a family member have a health problem caused by your home environment?
_____ Yes	_____ No
2. Building type:
_____ Single-family, detached			_____ Single-family, condo
_____ Mobile home			_____ Multifamily
3. Features:
_____Single story	_____ Multistory		_____ Attached garage
4. Lowest level of home:
_____ On-grade level	_____ Crawl space		_____ Below-grade basement
_____ Dirt floor	_____ Finished floor (material: )
5. Ownership:
_____ Self	_____ Other family member
_____ Tenant
6. Year built:________
Location:
_____ Industrial or agricultural pollution sources nearby (<1 mile)
_____ Livestock		_____ Commercial orchards, fields
_____ Hazardous waste site		_____ Industry or business
_____ Municipal landfills		_____ Underground tanks
7. Does anyone living in the household smoke tobacco products?
_____ Yes	_____ No
If yes, how many smokers at home?
Is there a child in your family exposed to smoke at day care or in cars?
_____ Yes	_____ No
8. Have there been renovations, interior decorating, or new furniture in the home in the last 3 years?
_____ Yes	_____ No
If yes, please describe: ________________________________________
9. How do you heat your home?
a. Primary energy source:
_____ Oil	_____ Natural gas		_____ Propane
_____ Wood	_____ Solar		_____ Coal
_____ Electric heat pump
b. Distribution of heat:
_____ Forced air	_____ Steam
_____ Radiant	_____ Hot water
c. Do you use another heat source?
_____ Yes	_____ No
d. Secondary energy source(s):
_____ Oil	_____ Propane		_____ Natural gas
_____ Wood	_____ Electric		_____ Heat pump
_____ Coal	_____ Solar		_____ Kerosene
e. Location of secondary heat source: ______________
f. If this heat source burns fuel, is it vented outdoors?
_____ Yes	_____ No
g. If you use a wood stove or fireplace, how often do you use it?
_____ Rarely	_____ Every week of winter
_____ Every day of winter
10. Do you have any of the following equipment or appliances?
Air filter (Describe __________________________________________________)
Humidifier (Describe _________________________________________________)
Air conditioner (Describe _____________________________________________)
Gas appliances:
_____ Kitchen stove	_____ Hot water heater		_____ Dryer
11. Do you or a family member have a hobby or home business that might involve
_____ biologic agents	_____ chemicals		_____ dusts
_____ fibers	_____ fumes		_____ radiation
_____ loud noise	_____ vibration		_____ metals
_____ paints
_____ extreme heat or cold
For those that apply, please list and/or describe the hobby: ______________________ ____________________________________________________
12. Is any part of your home damp or have you had a major leak or flood in your house?
_____ Yes	_____ No
If yes, please describe
13. Have any pesticides or herbicides been used in or around your home within the last year (including on pets)?
_____ Yes	_____ No
If yes, please describe
14. Have you ever tested your home for radon?
_____ Yes	_____ No
If yes, in which season of the year did you test your home?
_____ Spring	_____ Summer
_____ Fall	_____ Winter
In which part of your home did you conduct the test? ________________________
What was the length of test? ____________________________________
What levels of radon, if any, were found? ___________________________
Have any radon reduction measures been taken?
_____ Yes	_____ No
If yes, please describe ________________________________________________
____________________________________________________
If radon reduction measures have been taken, have the levels been rechecked?
_____ Yes	_____ No
If yes, were the radon levels reduced?
_____ Yes	_____ No
15. Where do you get your water supply?
_____ Bottled	_____ Municipal		_____ Private well or spring
If you get your water from a well, was the well _____dug or _____drilled?
When was the well last tested for contaminants? ____________________________
What were the results? _______________________________________________
___________________________________________________
___________________________________________________
16. Do you use a water treatment device in your well (e.g., filter or softener)?
_____ Yes	_____ No
If yes, please describe ________________________________________________
___________________________________________________
17. Do you have a _____septic system or do you use _____municipal sewers?
If you use a septic system, when was the tank last pumped? ____________________
18. Does any member of the household work at a job that might result in bringing chemicals home on his or her clothes or shoes?
_____ Yes	_____ No
If yes, please describe ________________________________________________
___________________________________________________
19. Have industrial chemicals been brought home from the workplace for domestic use?
_____ Yes	_____ No
If yes, please describe ________________________________________________
____________________________________________________

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Revised 2002-07-30.

Agency for Toxic Substances and Disease RegistryCase Studies in Environmental MedicinePediatric Environmental Health Basic Environmental Database

Table 5. Basic Environmental Database

Agency for Toxic Substances and Disease Registry
Case Studies in Environmental Medicine
Pediatric Environmental Health
Basic Environmental Database