Pre-Assessment Check List for Environmental Respiratory Evaluation

Instructions: To be reviewed and completed by caregiver(s) before the initial evaluation. As you will learn from reviewing this list, there are a number of potential environmental exposures at home or school that might contribute to your child’s respiratory symptoms. It will not be possible for the physician to cover all of these in detail at the time of your child’s evaluation. Please review this list in advance so as to alert your child’s physician to specific exposures at the time he or she is taking an environmental history.

  1. Please review this list of Potential Sources orCarbon Monoxide in your home. If any are present, mark the exposure source and alert the physician on or before your child’s evaluation.
  • Motor vehicle exhaust (especially enclosed garages)
  • Unvented kerosene and propane gas space heaters
  • Leaking chimneys and furnaces

Backdrafting from furnaces

  • Wood stoves and fire places
  • Charcoal grills
  • Gas appliances: stoves, dryers, water heaters
  • Gasoline powered generators
  • Gasoline powered equipment: lawn mowers, leaf blowers, etc.
  • Tobacco smoke
  1. Has any family pet died unexpectedly in the last year? This sometimes can be caused by excessive carbon monoxide exposure.
  1. Please review the following list** of commonly used Volatile Organic Compounds. If any of these are used in your home or at school, mark the agent and alert the physician on or before your child’s evaluation.


  1. Please review this list of Potential Occupational Environmental Exposures***. Does anyone in the family or does the child work in a job where some of these exposures might occur? If so please mark the exposure and alert the physician at the time of your child’s evaluation.


  1. Please review this list of Potential Hazardous Environmental Exposures in School Buildings and Class Rooms****.

Are any of these conditions or agents present in your child’s school? If so please mark the agent and alert the physician at the time of your child’s evaluation.


References

*Adapted from Chapter 7, Carbon Monoxide, in the Handbook of Pediatric Environmental Health, American Academy of Pediatrics, 1999.

** Adapted from Chapter 13, Indoor Air Pollutants, in the Handbook of Pediatric Environmental Health, American Academy of Pediatrics, 1999.

*** Adapted from Chapter 27, Workplaces, in the Handbook of Pediatric Environmental Health, American Academy of Pediatrics, 1999.

**** Adapted from Chapter 28, Schools, in the Handbook of Pediatric Environmental Health, American Academy of Pediatrics, 1999.