RESIDENTIAL INDOOR AIR QUALITY Q

Some Potentially Relevant Questions During a Mold Investigation

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	Musty smell	Air too humid
Hot pockets	Draftiness	Air too dry
Cold pockets	Stale or stuffy air	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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