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                                    E-mail: cntmc@rogers.com

Web-site: www.freewebs.com/cntmc

 

 

                           INDOOR AIR - HEALTH QUESTIONNAIRE

 

HEALTH CARE PROVIDER /DEPARTMENT OF HEALTH

Information

                                     

 

PART I: - Patient Information

 

Name: ___________________________________ Date of Birth: __/__/_____

Address:__________________________________ City: _________________

Province:____________________________Postal Code:_________________

 

Health Card No.: ______________________  Male  __  Female __

 

 

PART II: Health Information

 

List any operations (past 10 years) ______________________________________

__________________________________________________________________

 

List any medication taken or being taken (past 12 months) ___________________

__________________________________________________________________

 

List any drug allergies: _______________________________________________

__________________________________________________________________

 

List any food allergies: _______________________________________________

__________________________________________________________________

 

List any chemical sensitivities/allergies: _________________________________

__________________________________________________________________

 

List any other allergies: _______________________________________________

__________________________________________________________________

 

PART III – Residential/Business Environment

 

Type of Building ___ House ___ Townhouse__ Apartment__ Mobile Home ____

____ School_____ Portable ______ Office Building_____ Court House

 

Heating Method: ___ Gas ___ Electric ___ Oil_____ Other________________

Building Age: _________ (years)   Years Living in Residence/Work Place: _________

 

No.and types of pets:___________________________(if applicable)

 

List any visible stains, leaks, and cracks within the building: _____________________

___________________________________________________________________

 

Do you have a musty odor in your resident? ____ Yes ____ No,  If Yes explain ___

___________________________________________________________________

 

Do you have any visible mold or mildew? Specify where _____________________

__________________________________________________________________

 

Do you have difficulty breathing when at home/work, and is this difficulty experienced throughout the home/work place or only certain areas?  ___ Yes ___ No, 

 

If Yes, explain__________________________________________________________

 

Do you experience skin irritations/rashes when in your home ___ Yes ___ No,  If

Yes, please explain __________________________________________________

 

When in your home/work place do you experience any of the following on a regular basis?

 

Coughing, Sneezing, Wheezing, Shortness of Breath, Chest Tightening, Watery/Itchy Eyes, Sinus Problems, Headaches, Skin Irritations, Nausea, Abdominal Pain, Nose Bleeds, Blurred Vision, Chronic Fatigue, Weight Gain, Weight Loss:

 

List any other symptoms experienced while in your home _____________________

____________________________________________________________________

____________________________________________________________________

 

Do your symptoms increase after cleaning? __ Yes ___ No, If Yes, please explain

____________________________________________________________________

 

When away from your home, do your symptoms improve and/or go away? Explain

___________________________________________________________________

___________________________________________________________________

 

PLEASE DO NOT RETURN THIS QUESTIONNAIRE TO THE CNTMC – THANK YOU – Please submit it to your health care provider and a copy to your local Health Department – Environmental Division.

 

For any questions regarding this Questionnaire, please do not hesitate to contact us.

 

 

 

 

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