Prevention of childhood allergies and asthma
Family No. ______
Date: ____/____/_____
Based on the Lowell Healthy Homes Program’s questionnaire used by University of Massachusetts-Lowell.
Home or apartment
G1: How many rooms in the home? ______(do not include bathroom or hallways)
G2: What is the primary means for heating your home? (Mark all that apply)
1= Forced Hot Air 2= Radiators 3 = Indoor wood, coal or pellet stoves
4= Other______5= Don’t Know
G3: If forced hot air, ask:
When in use, is the air filter in the furnace changed at least every three months?
1= Yes 2= No 3= Don’t know
G4: Have any of the following been used to heat your home? (Mark all that apply)
1= Wood, coal or pellet stove 2= Fireplace
3= Unvented kerosene heater 4= Unvented gas heater or stove
5= Portable electric heater 6= gas cooking stove
7= None of the above 8= Don’t Know
G5: Are there any of the following in your immediate neighborhood? (Within 800 meters)
1= Dry cleaner 2= Gas station 3= Furniture refinisher
4= Restaurant 5= Bakery 6= Auto body shop
7= Truck loading/unloading area 8= City bus stop
9= Other source of odors or irritation______
10= Not paved street
G6: Do urban transport or loading trucks normally drive on your street?
1= Yes, often 2= Yes, occasionally 3= No
G7: Is there an emergency phone number near the phone?
1= Yes 2= No 3= Don’t know
G8: How often does someone in your house use air freshener?
1= Most days 2= Once a week or less
3= Once a month or less 4= Never
5= Other ______
G9: How often does someone in your house use candles/incense?
1= Most days 2= Once a week or less
3= Once a month or less 4= Never
5= Other ______
G10: How often does someone in your house use cleaning chemicals?
1= Most days 2= Once a week or less
3= Once a month or less 4= Never
5= Other ______
G11: What products do you regularly use to clean your kitchen?
G12: What products do you regularly use to clean your bathroom?
G13: What other sprays, polishes or chemical cleaners do you regularly use to clean your home?
G14: Are all the cabinets/drawers/closets where you store household chemicals locked?
1 = Yes 2 = No 3=Some
G15: If No, ask:
Which areas that contain chemicals are not locked? (Mark all that apply)
1= Drawers 2= Cabinets 3= Closets 4= Garage
5= Other ______
Cockroaches/ Mice/ Rats
G16: In the past month, have you seen signs of rats or mice? (Mark all that apply)
1= Rats 2= Mice 3= None
G17: If Yes, ask:
In the past month, on average, how often have you seen a rat or mouse?
1= Less than once per week 2= 1 to 6 times per week
3= At least once per day
G18: In the past month, have you seen or noticed signs of cockroaches?
1= Yes, once 2= Yes, more than once 3= No 4= Don’t Know
G19: If Yes, ask:
In the past month, on average, how many cockroaches do you see in a day?
1= Less than one per day 2= 1 to 9 per day
3= 10 to 19 per day 4= Over 20 per day
G20: In the past month, did you or a professional exterminator use pesticides in home?
1= Yes, once 2= Yes, more than once 3= No 4= Don’t know
G21: If Yes, ask:
What were the pesticides used for? (Mark all that apply)
1= Termites 2= Cockroaches 3= Ants
4= Other ______5= Don’t Know
G22: Have you applied any pesticides in the home?
1 = Yes 2 = No
G23: If Yes, ask:
What products have you used? (Ask for types of products: bomb/fogger, spray)
Dust Mites
G24: Do you have a working vacuum cleaner in the house?
1= Yes 2= No 3= Don’t Know
G25: If Yes, ask:
Does the vacuum have a special air filter, such as a HEPA filter, to keep dust in the vacuum?
1= Yes 2= No 3= Don’t Know
G26: What types of floor coverings occupy the floor space in the family/TV room? (Mark all that apply)
1= Carpet 2= Wood 3= Ceramic tiles
4= Vinyl tiles 5= Other ______
G27: Have you had your rugs cleaned in the past 12 months?
1=Yes 2=No 3=Don’t Know
Fill out questions G28 through G39 for the oldest asthmatic child and use the first initial of their first name.
If there is more than one asthmatic child in the home and he/she sleeps in a different room than the first asthmatic child, answer duplicate set of questions (G28 to G39) at end of questionnaire.
First Initial: ______
G28: Where does the asthmatic child usually sleep?
1= Child’s bedroom 2= Parent’s bedroom 3= Living/family room
G29: Is the room where the asthmatic child usually sleeps air conditioned during the summer months?
1= Yes 2= No
G30: What types of floor coverings occupy the floor space in the asthmatic child’s bedroom? (Mark all that apply)
1= Carpet 2=-Throw rugs 3= Wood
4= Ceramic tiles 5= Vinyl tiles 6= Other ______
G31: Which of the following is currently in the asthmatic child’s bedroom? (Mark all that apply)
1= Beddings made of feather down or wool 2= Allergen proof pillow cover
3= Allergen proof bed coverings 4= curtains or drapes
5= Stuffed toys in bed
G32: How often do you dust the child’s room?
1= Once per week 2= Two times per month 3= Once monthly
4= Less frequently than once per month
G33: How often to you mop the floor/vacuum the rugs in the child’s room?
1= Once per week 2= Two times per month 3= Once monthly
4= Less than once per month
G34: How often do you wash the throw rugs in the child’s room?
1= Once per week 2= Two times per month 3= Once monthly
4= Less than once per month 5 = Not applicable
G35: How often do you wash the bed sheets?
1= More than once per week 2= Two times per week
3= Once or twice per month 4= Less once per month
G36: Are the bed sheets washed using the hot water cycle of the washing machine?
1= Yes 2= No 3= Don’t know
G37: Are the bed sheets dried using the hot cycle of the drying machine?
1= Yes 2= No 3= Don’t know
G38: How often do you wash the blankets?
1= More than once per week 2= Two times per week
3= Once or twice per month 4= Less once per month
G39: How often do you wash the bed covers?
1= More than once per week 2= Two times per week
3= Once or twice per month 4= Less once per month
Dampness/ Mold
G40: Is any part of your home or apartment air conditioned during the summer months?
1=Yes 2=No 3=Don’t know
G41: If Yes, ask:
Which rooms have air conditioning? (Mark all that apply)
1= All rooms (Central air-conditioning)
2= Living room
3= All bedrooms
4= Only sensitized child’s bedroom
(If only parents’, do not circle any)
G42: If central air conditioning, ask:
When in use, is the air filter changed at least once per month?
1= Yes 2= No 3= Don’t know
G43: If window AC or Minisplit units, ask:
When in use, is the air filter changed/cleaned at least once per month?
1= Yes 2= No 3= Don’t know
G44: Do you know of any surfaces inside your home that currently have mold or mildew?
1= Yes 2= No 3= Don’t Know
G45: If Yes ask:
Which rooms have been affected? (Mark all that apply)
1= Bathroom(s) 2= Sensitized child’s bedroom
3= Other living area(s) 4= Kitchen
5= None of the above 6= Don’t Know
G46: Do you have peeling paint or visible water damage on any walls or ceilings?
1= Yes 2= No
G47: If Yes, ask:
Which rooms have been affected? (Mark all that apply)
1= Bathroom(s) 2= Sensitized child’s bedroom
3= other living area(s) 4= Kitchen
5= None of the above 6= Don’t Know
G48: Do you have a bathroom fan that vents to the outside?
1= Yes 2= No 3= Don’t Know
G49: Do you have a clothes dryer in your living area?
1=Yes 2=No 3=Don’t Know
50: If Yes, ask:
Does it vent to the outside?
1= Yes 2= No 3= Don’t know
G51: In the wintertime, how often do windows other than bathroom and kitchen fog up or have water on the inside of the window?
1= Never 2= Rarely 3= Sometimes 4= Most of the time
5= Always 6= Don’t Know
G52: If Yes, ask:
Where? ______
G53: Then ask:
Do you know the reason? (Ask: when shower, when use vaporizer, night time, etc.) ______
G54: Have you noticed any water leaks under sinks or toilets?
1= Yes 2= No 3= Don’t know
G55: If YES, ask:
Where? (Mark all that apply)
1= kitchen sink 2= bathroom sink 3= toilet
Pets
G56: Do you have any dogs, cats, other furry pets or birds? (Mark all that apply)
1= Dogs 2= Cats 3= Pet mice, rats, hamsters or gerbils
4= Other furry pets: ______5= Birds
6= None of the above
G57: If there are pets in the home, ask:
Are pets ever in the bedroom of your sensitized child/children?
1= Yes 2= No
G58: If Yes, then ask:
How often are pets in the asthmatic child’s room?
1= Rarely 2= Sometimes 3= Most of the time
4= Always 5= Don’t Know
Smoking
G59: Do any adults who live here smoke in the home?
1 = Yes 2 = No
G60: If Yes, ask:
How many adults smoke in the home? ______
G61: Do visitors ever smoke in the home?
1 = Yes 2 = No
AC Filters
G62. What type of AC is in the home?
1= Central AC 2=Window AC or minisplit 3= Wall AC 4= None
If central AC, check air filter:
G63. Does the filter appear clean?
1= Yes 2= No 3= Not accessible
If filter not clean,
Record the manufacturer and model number of the filter
G64. Manuf.: ______
G65. Model: ______
If window or wall AC, check individual air filters:
Location 1:
G66. Location of unit: ______
G67. Does the filter appear clean?
1= Yes 2= No 3= Not accessible
Location 2:
G68. Location of unit: ______
G69. Does the filter appear clean?
1= Yes 2= No 3= not accessible
Location 3:
G70. Location of unit: ______
G71. Does the filter appear clean?
1= Yes 2= No 3= Not accessible
If cooler, ask:
G72. Do this use straw?
1= Yes 2= No
G73. Is there presence of mold or rust?
1= Yes 2= No
G74. If Yes, extent: Slight Moderate Severe
G75. Total area: ______
Location code: B: Bathroom, C = Kitchen; S = Living room; DN = Children’s bedroom
B1. Approximate dimensions of bathroom: ____ m. x ____ m.
B2. Is there evidence of water leaks under or around sink, toilet, shower, etc.?
1= Yes 2= No
B3. If Yes, extent: Slight Moderate Severe
B4. Describe location:
B5. Is there evidence (visual or odor) of mold or mildew?
1= Yes 2= No
Location 1:
B6 If Yes, describe extent: Slight Moderate Severe
B7. Total area: ______
B8. Describe location (sink, shower, etc.______
Location 2:
B9 If Yes, describe extent: Slight Moderate Severe
B10. Total area: ______
B11. Describe location (sink, shower, etc.______
B12. Is there evidence of mice, rats or cockroaches?
1= Yes 2= No
B13. If Yes, select all that apply:
1= Mice/rats (look for rodents and droppings)
2= Cockroaches (look for eggs, feces, insects)
B14. Floor coverings (underline if you have any in home):
1= Carpet 2 = Throw rugs 3 = None
B15. Is there a vent?
1= Yes 2= No
If Yes, ask:
B16. Is vent ventilated to outside?
1= Yes 2= No
B17. Is there evidence of water leaks around windows?
1= Yes 2= No
B18. Are there any holes wider than 0.6cm that would allow rodents or pests access to the room? (Look under sink, along floorboards, etc.).
1= Yes 2= No
If Yes:
B19. Describe extent and location: ______
B20. Are household chemicals or medications stored in the bathroom within a child’s reach?
1= Yes 2= No
If Yes:
B21. Where? ______
B22. Are these locations protected from child access?
1= Yes 2= No
C1. Approximate size of kitchen: ______m. X ______m.
C2. Heating source for cooking:
1= Gas 2= Electricity 3= Other: ______
If Gas:
C3. Is there a hood or vent present?
1= Yes 2= No
C4. Is hood/vent ventilated to outside?
1= Yes 2= No
C5. Is the stove equipped with knob locks?
1= Yes 2= No 3= No, but knobs are not within child’s reach
C6. Is there evidence of water leaks under or around sink, dishwasher, etc.?
1= Yes 2= No
C7. If yes, extent: Slight Moderate Severe
C8. Describe location: ______
C9. Is there evidence (visual or odor) of mold or mildew?
1= Yes 2= No
Location 1:
C10. If Yes, extent: Slight Moderate Severe
C11. Total area: ______
C12. Describe location (under sink, walls, etc.)______
Location 2:
C13. If Yes, extent: Slight Moderate Severe
C14. Total area: ______
C15. Describe location (under sink, walls, etc.)______
C16. Is there evidence of mice, rats or cockroaches?
1= Yes 2= No
C17. If Yes, select all that apply:
1= Mice/rats (look for rodents, droppings)
2= Cockroaches (look for eggs, feces, insects)
C18. Is there visible trash/food debris evidence on kitchen surfaces/floor?
1= Yes 2= No