Appendix 1: Asthma Triggers Exposure History

Course: WB 2490
CE Original Date: November 28, 2014
CE Renewal Date: November 28, 2016
CE Expiration Date: November 28, 2018
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Introduction

Adapted from The National Environmental Education and Training Foundation. Environmental Management Of Pediatric Asthma Guidelines. http://www.neefusa.org/health/asthma/asthmaguidelines.htmexternal icon, 2005 Aug.

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

Have you noticed whether dust exposure makes your child’s asthma worse?
Yes [  ] No [  ] Not sure [  ]
Have you used any means for dust mite control? Which ones?____
Yes [  ] No [  ] Not sure [  ]

 

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

Do you have any furry pets?
Yes [  ] No [  ] Not sure [  ]
Have you seen rats or mice in the home?
Yes [  ] No [  ] Not sure [  ]

 

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)?
    Yes [  ] No [  ] Not sure [  ]

 

Cockroach Allergen

Have you seen cockroaches in your home on a regular basis? (i.e., weekly or daily)
Yes [  ] No [  ] Not sure [  ]

 

Additional Questions:

  • Approximately how many cockroaches do you see in your home per day? __________
  • Do you see evidence of cockroach droppings?
    Yes [  ] No [  ] Not sure [  ]
  • How do you get rid of the cockroaches? ____________________

 

Mold/Mildew

Do you see or smell mold/mildew in your home?
Yes [  ] No [  ] Not sure [  ]

 

Is there evidence of water damage in your home?
Yes [  ] No [  ] Not sure [  ]

 

Do you use a humidifier or swamp cooler?
Yes [  ] No [  ] Not sure [  ]

 

Additional Questions:

  • Where do you see mold growth in your home?
    Attic ____________ Garage _________
    Basement _________ Laundry room _________
    Bathroom ________ Other _________
    Bedroom __________
  • How large an area is the mold growth? _________________________
  • Do you have problems with moisture or leaks in your home?
    Yes [  ] No [  ] Not sure [  ]
  • Do you frequently have condensation on your windows?
    Yes [  ] No [  ] Not sure [  ]
  • 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

Do any family members smoke?
Yes [  ] No [  ] Not sure [  ]

 

Does this person(s) have an interest or desire to quit?
Yes [  ] No [  ] Not sure [  ]

 

Does your child/teenager smoke?
Yes [  ] No [  ] Not sure [  ]
  • How many cigarettes per day? ______
  • Does he/she (they) smoke in the house? ______
    Outside? _____ Both inside and outside? ______ In the car?

 

Additional Questions:

  • 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

Have you had new carpets, paint, or other changes made to your house in the past year?
Yes [  ] No [  ] Not sure [  ]

 

Does your child or another family member have a hobby that uses toxic materials?
Yes [  ] No [  ] Not sure [  ]

 

Has outdoor air pollution ever worsened your child’s asthma?
Yes [  ] No [  ] Not sure [  ]

 

Does your child play outdoors when an Air Quality Alert (i.e., ozone, particulate) is issued?
Yes [  ] No [  ] Not sure [  ]

 

Do you use a wood burning fireplace or stove?
Yes [  ] No [  ] Not sure [  ]

 

Do you use unvented appliances such as a gas stove for heating your home?
Yes [  ] No [  ] Not sure [  ]

 

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?
    Yes [  ] No [  ] Not sure [  ]
  • 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?
    Yes [  ] No [  ] Not sure [  ]
  • Do you ever notice a chemical type smell in your home?
    Yes [  ] No [  ] Not sure [  ]
  • 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 half mile of a major roadway or highway?
    Yes [  ] No [  ] Not sure [  ]
  • An area where trucks or other vehicles idle?
    Yes [  ] No [  ] Not sure [  ]
  • A major industry with smokestacks?
    Yes [  ] No [  ] Not sure [  ]
  • Is residential or agricultural burning a problem where you live?
    Yes [  ] No [  ] Not sure [  ]
Page last reviewed: December 29, 2014