Home Exposures 1. Which of the following do you have in your home? ____ air conditioner ____ fireplace ____ electric stove ____ central heating ____ air purifier ____ woodstove ____ gas stove ____ (gas or oil?) 2. In approximately what year was your home built? 3. Have there been any recent renovations? 4. Have you recently gotten new carpet or furniture or have you refinished furniture? 5. Do you use pesticides around your home or garden? 6. What household cleaners do you use? 7. List all hobbies done at your home: Are any of the agents listed for work exposures encountered in hobbies or recreational activities? Is any special protective equipment or ventilation used during hobbies? 8. What are the occupations of other household members? 9. Do they have contact with dust or chemicals at work or during leisure activity? 10. Is anyone having symptoms related to this? 320 Guideline continues on next page