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IAQ Questionnaire

Mold Inspection Questions

1. Type of structure: Single unit house ______Duplex ____ Apartment____

Town Home______ Office building________ Other___________________

One story? ________ two stories? _____ multi levels? ______

2. Is the occupant above ground level? ____ below ground? ____
3. Age of structure: _________years
4. Length of time at current building: ______ years
5. What type of exterior siding does the structure have? __________
6. How many people are in this building? _________________
7. Does the structure have? Moisture on windows/ walls
Hot pockets
Cold pockets
Musty smell
Draftiness
Stale or stuffy air
Air too humid
Air too dry
Strange odors
8. If there is a basement, is it wet or dry? Wet

Dry

 
9. Is there a crawl space? Yes

No

If yes, is the soil there covered or bare? Is the space ventilated?
10. Are there musty items in the building (e.g., damaged or antique furniture, old books)? Yes

No

If yes, please explain:
11. Have there ever been major plumbing, basement, or roof leaks? Yes

No

If so, please explain extent of water damage.
12. Have carpets or rugs ever remained wet for more than 24 hours? Yes

No

 
13. Are insects frequently seen? Yes

No

 
14. Is there central heating? Yes

No

If not what type: electric base-boards, hot water radiators, gravity or propane or kerosene heaters?
15. Is there central air conditioning? Yes

No

How often is it serviced?
16. What type of filter is used on the furnace? Yes

No

If yes, how often is it changed?
17. Are there increased symptoms when the central heat or central air conditioning (if available) is turned on? Yes

No

 
18. Are there window unit air conditioners? Yes

No

Are they periodically cleaned?
19. Are attic, ceiling, or room fans used? Yes

No

 
20. Have any recent changes been made (painting, weatherization, remodeling, purchase of new furniture, etc.)? Yes

No

Please describe:
21. If yes, were there changes in anyone’s health after these improvements were made? Yes

No

Please explain:
22. Are there vines growing on the outside siding? Yes

No

 
23. Are there a lot of indoor houseplants? Yes

No

 
24. Is a humidifier used in the winter? Yes

No

If yes, is it cleaned annually? Is the filter changed before heating season?
25. Are symptoms stronger in any particular location? Yes

No

If yes, where?
26. Do more than one person in the building have these same or similar symptoms? Yes

No

explain?
27. Do symptoms get better when away from the building? Yes

No

 
28. Have there been similar health problems in other residences lived in or buildings occupied? Yes

No

N/A

If yes, when, where?

SYMPTOMS:

29.Please mark how often these symptoms are experienced: 

EAR, NOSE, AND THROAT Always

(4)

Often

(3)

Occasionally

(2)

Seldom

(1)

Never

(0)

Stuffy or runny nose          
Itchy nose          
Frequent sneezing          
Frequent colds, flu          
Sore throat          
Short of breath, asthma or wheezing          
Bronchitis          
Frequent cough          
Coughing up phlegm          
Earache/ ear infection          
Ringing in ears          
           
EYES          
Eyes watery, red, irritated, itchy          
           
NEUROLOGICAL          
Dizzy, lightheaded          
Difficulty remembering          
Difficulty concentrating          
Depressed          
Always tired          
Headaches          
Fainting          
Convulsions/seizures          
           
SKIN          
Irritated skin, rash or eczema          
           
GASTROINTESTINAL          
Heartburn          
Diarrhea          
Stomach pains or cramps          
Bloating or constipation          
Nausea or upset stomach          
           
OTHER          
Muscle pain, twitches or cramps          
Joint pain          
Chest pain/ tightness          
Heart condition          
Fever          
Other ________________          

30. Do you recall when these health problems started? _________________________________

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