Medical Providers: Questions to Identify
Patient Environmental Asthma Triggers

Question

Yes

No

Comments

Tobacco Smoke

Does the patient smoke?

• Is the patient exposed to smoke at home, work or in a vehicle?

Allergens

Does the patient have symptoms year round?

• Are pets allowed indoor? What type?

• Are there any rooms in the home that show signs of moisture or dampness? ~Indicates dust mites, mold

• Is there any visible mold in the home or an earthy or musty odor?

• Has the patient seen cockroaches or droppings in the home recently?

• Assume exposure to dust mites

Do symptoms get worse at certain times of the year?

• Early spring? ~Tree allergy

• Late spring? ~Grass allergy

• Late summer to fall? ~Weed allergy

• Summer and fall? ~ Mold allergy- Alternaria, Cladosporium

Irritants

Is a wood-burning stove or fireplace used in the patient’s home?

• Is it properly vented?

• Does smoke enter the home?

Does patient use unvented stoves or heaters?

• Does the patient smell gas?

Does exposure to strong odors adversely affect the patient?

• What type? Perfumes, cleaning products, strong cooking odors, etc

Work, School, Child Care

Does the patient have asthma symptoms during the week, but not on the weekends?