Environmental History Indoor Air Quality Survey

Patient First Name

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Patient Last Name

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New studies show that indoor air can be three to five times more polluted than outdoor air.

Please take a few moments to go through yam- home and answer all of these questions regarding the household and personal products you are currently using. It is important that you list the exact brand name, type, scent/fragrance, etc.

What type of laundry detergent do you use?

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What type of liquid fabric softener do you use?

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What type of dryer sheets do you use?

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What cleaning products do you use:

A. When cleaning around the kitchen?

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B. When cleaning dishes?

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C. In the bathrooms?

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D. In other areas of the house (bedrooms, living room, etc.)?

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Do you use Febreze or other spray/aerosolized air fresheners around your home?

Please select an option.

Do you have any plug-ins at home?

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Any timed-release air fresheners?

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Scented candles?

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Reed diffusers?

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Do you wear perfume or cologne?

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Do you use any talcum powder or shower-to-shower powder?

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Do you use any lotion?

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if yes, what kind?

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When/if using, what type of sunscreen de you use?

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When/if using, what kind of shaving cream do you use?

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Do you use any hairspray, hair gels, or other similar hair care products?

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If yes, what kind?

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What kind of deodorant do you use?

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What kind of body wash or soap do you use?

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What kind of shampoo do you use?

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What kind of conditioner do you use?

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What kind of conditioner do you use?

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When dusting and/or vacuuming around the house, do you wear a mask?

Please select an option.

When doing yard work, do you wear a mask?

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Do you have allergenic zip covers around your:

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