Asthma Triggers Assessment

> General Demographics

Age :

Sex :

Male Female

How tall are you?

Feet Inches

Weight :

Lbs

Zip code
(of your residence)

Does your occupation include any of the following?
(Check all that apply)

	Exposure to fumes or odors from cleaning agents, sprays or other chemicals
	Exposure to isocyanates, plant or animal products, smoke, gasses or fumes
	Exposure to excess heat, dust or humidity
	None of the above

Does your home contain any of the following items or appliances?
(Check all that apply)

	A gas-cooking range
	A wood-burning stove or fireplace
	An unvented kerosene, oil or gas heater (not an installed furnace with a flu-pipe vent)
	None of the above

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