Home assessment for dust mite allergens (supplemental questions)

Housing characteristics
Building
Are all your windows sealed shut or don’t open?	□ yes	□ no
How long have you lived in this home?	___ years
If <1 year, did you move from a region of the       country that might have high levels       of dust mites? (see climate maps)	□ yes	□ no
If YES, did you bring furniture from your       previous home?	□ yes	□ no
Is any part of your living area below ground       level?	□ yes	□ no
If YES, does this area ever get wet or stay wet for       long periods (>1 week)?	□ yes	□ no
Heating, ventilation, and cooling
Do you use a dehumidifier in your home?	□ yes	□ no	□ N/A
During winter, are some outside walls cold?	□ yes	□ no	□ don’t know
Does your home sometimes smell “ stuffy,”       “ stale,” or “musty”?	□ yes	□ no
Does your air conditioner ever leak water onto       walls or carpeting?	□ yes	□ no	□ N/A (no A/C)
Bedroom characteristics
Do you have upholstered furniture in your child’s   bedroom?	□ yes	□ no
Do you allow your child to have stuffed animals/   toys in the room?	□ yes	□ no
Dust reservoirs (overall home)
Do you have cloth sofa or chairs?	□ yes	□ no
Do you have cloth curtains?	□ yes	□ no
Can you see dust or dirt on your furniture, walls,   ceiling, and curtains?	□ yes	□ no
Do you have wall-to-wall carpeting in more than   half the rooms in your home?	□ yes	□ no
Do you have wall-to-wall carpeting in your   kitchen or bathrooms?	□ yes	□ no
Do you not own a vacuum cleaner?	□ yes	□ no
Do you vacuum less than once a week?	□ yes	□ no
Dampness
In the past 12 months, have you noticed   condensation on windows in your home?	□ yes	□ no	□ don’t know
If YES, does moisture regularly build up on your   windows/walls?	□ yes	□ no
In the past 12 months, have you had any water   leaks?	□ yes	□ no	□ don’t know

Abbreviations: A/C, air conditioning; N/A, not applicable.

This questionnaire can be given to the patient. Affirmative (ie, YES) answers indicate potential dust mite allergen exposure.