Indoor Air Quality

If you are having health problems associated with your home, print the following questionnaire. Then answer the questions, one by one. They will probably lead you towards a solution. 

Residential Indoor Air Quality Environmental Questionnaire©

This form was created by Daniel Friedman/Jeffrey May/William Coull ©2000-2008 All rights reserved 

Name: ____________________________________________Date:________

Address:______________________________________________ Inspector: _____

Complaints/Symptoms: (Per occupant):

Occupant's suspected cause:_______________________________ Don't Know

Time of day/season when more severe: Morning,   Evening,   No Difference

House Information: Age of House:_____ Type Of Structure: 1-Fam,  2- Fam,  Multiple

1Story, 2Story, 3Story Bedrooms on: ______level

Garage: Attached,   Under,   Detached,   None      Other_________________

Basement: Finished,   Unfinished,   Both

Carpeting: At:____________ Area Wall-to-wall Material: Wool,   Synthetic

Carpeting: At:____________ Area Wall-to-wall Material: Wool,   Synthetic

Carpeting: At:____________ Area Wall-to-wall Material: Wool,   Synthetic

Carpeting cleaned: _______ Used: Steam,   Water,   Dry Chemical: ________

Recent Construction: ____________________________________________

Materials Used: (Particle board,  adhesives,  carpeting,  painting, etc.) _______

Comments: ______________________________________________________

________________________________________________________________

Heating Systems:

Type: Hot Air Furnace,   Hot Water Boiler,   Steam,   Stove/Fireplace.

Fuels: Oil,   Gas,   Electric,   Kerosene,   Wood/Coal __________

Recent Problems Fuel Leak,   Puff-Back,   Spillage,   Soot/Dust,   Noises

Ductwork: Last Cleaned_____________ Return Ducts at:_________________

Fiberglass In Blower Compartment? Yes     Condition: _________________

Kick-Space Heaters  In kitchen,   In bath

Air Filters: Electronic,  Fiberglass furnace filter,   Electrostatic media filter,   Accordion Paper

Frequency of changing/cleaning filters:________________________

 

Humidifiers: (Devices to add moisture to the air, usually used in winter)

Type: At Furnace,   In Room Leaks/Corrosion/Mold: _____________________

 

Dehumidifiers: (Devices to remove moisture from the air, used in humid weather and/or damp locations)

Present,   In Use Last Cleaned: _________ Coil Condition _____________

 

Air Conditioning: Central,  Room Units     Located at:___________________________

Return Air Locations:____________ Near Bathroom,  Garage,  Utility Room ?

Duct Insulation: Fiberglass Lining? Yes, No    Condition: Clean,   Dirty,   Moldy Cleaned__________

Condensate Handling: Gravity drain,  Pump Leaks Yes,  No    Cleaned______

Condition of Pan:___________________

 

Attic:

Whole House Fan: Yes     Frequency of Use:___________ Not Used

Condensation: None,   Light,   Heavy,  No Access

Roof Fan: Yes,  None,  Not Used

Roof Leak History: ________________________________________________

 

Water Entry And Moisture History:_________________________

_______________________________________________________________

Mildew Visible @ ___________________________ Mildew Odors,  Wall Stains

Other Water Entry Signs: Partition Walls,  Closets,  Carpets/Rugs Present

Windows Generally: Shut,  Open,  Varies

Hours Basement Used/Occupied Per Week:______ Office,  Exercise space,  Other

Dehumidifiers: Present,  In use Last cleaned____________ Coil Condition________

 

Clothes Dryer at: __________________ Vented to:__________________

Washing Machine at:_______________ Leaks:__________________

Kitchen Stove: Electric, Gas    Ignition: Match,  Pilots,  Automatic/Electronic

Refrigerator: Drip Tray Present Last Cleaned____________ Ice Maker Leaks

Dishwasher: Leaks,  Soil Under Unit

 

Odors Mold, Mildew,  Soot, Dust, Leak,  Stains Location:___________________

Odors Mold, Mildew,  Soot, Dust, Leak,  Stains Location:___________________

Odors Mold, Mildew,  Soot, Dust, Leak,  Stains Location:____________________

Other Room Observations: (Drafts,  Leaks,  Insect or Rodent Pests) ___________

 

Pets: (list all)____________________________________________________

Do Pets Sleep on Furniture? Yes,   No    Locations: ____________________

House Plants: Ficus Benjamina (ornamental fig)

Bedding: Allergy control covers: In Use,   Not Used Linens washed in: Hot,  Cold Water.

Feather: Pillows,   Quilts,   Mattresses ___________________

How Old Are Pillows? _____________ How Old Are Mattresses? ____________

Furniture: Padded Cushions,   Fleecy Materials _________________

Fragrances Used: Hair Spray,  Perfumes,   Air Fresheners

Candles/Oil lamps Burned In Home: Frequency_____________ Scented,   Incense

 

Vacuum Cleaner Type: Canister,  Upright,  Hepa Filter

Central Vacuum: Discharges: Inside,  Outside

Cleaning Service: Yes         Uses their own vacuum cleaner: Yes,   No

 

                    Where Are Pesticides/Fertilizers Stored: __________________________

House Treated For: ____________ Date/Frequency ________

Termites,  Carpenter Ants,  Other Insects,  Rodents: ________________

Pesticides and Chemicals Used: _______________

Treatment Company: _______________   Homeowner

Unusual number of spider webs in basement, crawl-space, house:__________

Carpet Or Furniture Treated For: Mites,  Fleas

 

Lawn Treated With Pesticides or Herbicides? This Lawn,  Neighbors’ _____

Distance to swamps/wetlands/Dry-Cleaners/Laundry/Compost ____________

Mildew Or Molds Growing On Exterior: Yes, No.    

 Where: _______________________

 

Comments/Opinions About Sources Of Complaint: __________________

_______________________________________________________________

________________________________________________________________

Regarding these complaint(s): 

Consultation has also been with: Medical Professional,  Industrial Hygienist,  

Home Inspector,  No- One Else ________________________________________

 ©Copyright 1999-2007 Daniel Friedman/Jeffrey May/William Coull, all rights reserved.

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