What type of dwelling do you live in? Apartment Townhouse House Duplex (multi-family home) Organic Farm Nonorganic Farm Where is your home located? (check what applies) Urban Suburban Rural Agricultural Rural Non-Agricultural Near a pollution producing structure (bus station, factory, waste site, etc) When was your home built? After 1978 Before 1978 Before 1970 I don't know Have you tested the paint on your walls or windowsills? yes, it tested positive, but was cleaned up yes, it tested positive and is not yet cleaned yes, it tested negative No Do you have an attached garage? Yes No Are the doors between the house and garage weatherstripped? Yes No Not applicable Check all rooms that have wall-to-wall carpets. Bedrooms Living or family rooms Bathrooms None Check what you have on your windows. Curtains Pleated Shades Vinyl miniblinds None Do you wipe your feet on a doormat or remove your shoes upon entering your home? Never Sometimes Always Check the following items you use dust mite covers on. My mattress Children's mattress My pillows Children's pillows None What age are your non-adult children? (check all that apply) 0-2 years 3-6 years 7-11 years 12-18 years I have no children I have no children, but children are/will be in my home regularly Do any of your children have asthma? Yes No No children at home Check all toys that you purchase for your children. Arts & crafts Wooden toys Cloth toys Stuffed animals Rubber or soft plastic toys Hard plastic toys Board Games How often do you wash or freeze stuffed animals? About once per month 2-3 times per year Rarely or never My child does not have stuffed animals Does your house have any of the following? (check all that apply) Not applicable Wooden deck or wooden patio Outdoor wooden playset or wooden sandbox Wooden flower boxes Do you allow smoking in your home? Yes No Have you installed carbon monoxide detectors in your home? Yes No Check all factors that describe your fireplace or wood stove: I do not have a fireplace or woodstove, or I use it infrequently I burn a fire once per week I burn a fire everyday I cleaned my chimney(s) within last year I cleaned my chimney(s) over one year ago I never clean my chimney(s) Check all the factors that apply: I have not tested my home for radon. I have tested my home for radon, but don't do it annually. I test my home annually for radon. My home has tested positive for radon. My home has a radon remediation system. Is your home Drafty Not drafty or "air tight" Check the areas where your house has exhaust fans. None Bathroom Above the stove Basement Attic What do you do when cooking with a gas stove? Always use exhaust fan Open window before cooking Only use fan or open window when something is burning Do you use the exhaust fan in the bathroom? Seldom Always Only when very steamy How do you ventilate when using glues, paints, building or art products? None Open windows Open windows and turn on a fan Use custom venting system What is the humidity level in your home for Summer? High humidity Medium humidity Low humidity How about in the Winter? High humidity Medium humidity Low humidity Is mold a problem in your home? Yes No I don't know Do you ever use one of the following? Humidifier De-humidifier, airconditioner to decrease humidity Do you use low or no-VOC paints and glues (formulated to release fewer fumes) for decorating and building projects? Yes No Not applicable What kind of furniture do you have? Hardwood Upholstered Required Assembly, made of particle board How often do you have your gas appliances (stove, dryer or water heater) serviced and maintained? Once a year Every few years When broken Never have How often do you replace or clean furnace and air conditioner filters? Several times per year Once a year Never have or can't remember Not applicable What is the source of your drinking water? Municipal or public source Private well Bottled water Regardless of your water source, check one answer in the first group and one answer in the second group, if applicable. I have never tested my water. I have tested my drinking water only once in the past five years. I test my drinking water every year. Testing shows no contaminants Testing revealed contaminants, but I have not taken steps to remove them. Testing revealed contaminants, and I have taken steps to remove them. During the past year, have you read the consumer confidence report from your water company? Yes No Do you filter your drinking water? Yes No Does your home have either lead or copper pipes? Yes No I suspect that it does I don't know If your home has lead/copper pipes, how do you reduce your family's risk for lead poisoning? not applicable Flush lines by running taps for one minute Filter drinking water only Filter drinking water and bathing water Do nothing PART 1 I hope that this is helpful to you guys. I found it interesting. Study done by CHEC. Have a great weekend. Angie P www.dahodreams.fourpointwellness.com