In-home Environment Assessment Form

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Sheena Booth
5 years ago
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1 General Information Member age: Initial In-home Visit: / / Housing Information Number of persons living in the home: Adults Member gender: Follow-up In-home Visit: / / Children Public Housing Single Home Row Home Rent/Lease Private Housing Duplex Apartment Own Townhome Re-visit only: Is this the same home where the initial assessment was conducted? General Home Environment Information Does anyone smoke in the home or is there evidence of smoking (ashtrays, smell)? Is smoking allowed in the home? Is smoking limited to certain rooms within the home? Are there cockroach problems, either reported or evidence of (see cockroaches or pieces of, see droppings)? Are there rodent problems, either reported or evidence of (see rodents or other pests or rodent droppings)? Does a pet(s) live here? If yes to a pet(s), what type of pet(s) live here? How is the home heated? Gas Oil Wood Stove Kerosene Electric Other: How is the home cooled? Fans Air Conditioner(s) Central Air Open Windows Are there rugs or carpet in the home? Is the flooring swept with vacuum or broom? Is there evidence or reports of structure damage? Is there evidence or reports of water damage? Is there evidence of clutter? Is there evidence or reports of odor from chemicals or scented home products, i.e. sprays, plug-ins, candles? (skip next question)

2 If yes, what odors were evidenced or reported? Cleaning Agents Paints Pesticides Spray Deodorizers Candles Perfumes Other, please describe Is there evidence of ongoing housekeeping? Room Specific: Kitchen Is there evidence of cleaning agents? Is there evidence of improperly stored garbage or trash? Is there improperly stored food or food particles that would entice roaches and rodents? Is there any evidence of water leaks or plumbing issues? Is there proper cooking ventilation? Room Specific: Living Room Is the living room furniture upholstered? Is there evidence of dust build-up? Is there evidence of a fireplace? Is the area in good repair? Room Specific: Basement, Workroom, or Laundry Room Is there evidence of cleaning agents? Is there evidence of stored chemicals or solvents, i.e. paints, varnishes, and pesticides? Is there evidence of clutter? Are floor drains properly working? Is there evidence of moisture? Is there evidence of mildew or mold? Is there proper ventilation? Room Specific: Bathroom(s) Is there evidence of cleaning agents? Is there evidence of spray deodorizers, hair sprays, perfumes, or colognes? (skip next question) If yes, what odors were evidenced or reported? Cleaning Agents Paints Pesticides Spray Deodorizers Candles Perfumes Other, please describe Are drains properly working?

3 Is there evidence of excess moisture? Is there evidence of mildew or mold? Is there proper ventilation? Room Specific: Member s Bedroom or Sleeping Area Is there evidence of perfumes, colognes, hairsprays, candles or other strong scents? (skip next question) If yes, what odors were evidenced or reported? Cleaning Agents Paints Pesticides Spray Deodorizers Candles Perfumes Other, please describe Is there evidence of smoking in this area? Is there proper ventilation? Is there evidence of excess moisture? Is there evidence of clutter? Does a pet stay or sleep in this room? Are the furniture, walls, flooring, and ceiling maintained? What type of bedding and pillows are used? Hypoallergenic Down or Feathered Cotton Wool Synthetic Are there stuffed animals? Asthma Self-Management Education (specific to adults age 18 years and older): Has a doctor or other health professional ever taught you how to recognize early signs or symptoms of an asthma episode? Has a doctor or other health professional ever taught you what to do during an asthma attack? Do you have an asthma action plan?, skip next question Do you use your asthma action plan? Do you know what a peak flow meter is? Has a doctor or other health professional ever taught you how to use a peak flow meter to adjust your daily medications? Has a doctor or other health professional ever given you an asthma action plan? Have you ever taken a course or class on how to manage your asthma? Have you ever used a prescription inhaler? Has a doctor or other health professional ever showed you how to use the inhaler? Has a doctor or other health professional ever watched you use your inhaler?

4 In the last month (or past 30 days), how many days would you say you had symptoms of asthma? 0 5 days 6 10 days days days days days In the last month (or past 30 days), how many days of work or school did you miss because of asthma? 0 5 days 6 10 days days days days days Asthma Self-Management Education (specific to children age 0-17 years): The last time your child left the hospital (due to an asthma episode) did a health professional talk with you or your child about how to prevent serious asthma attacks in the future? Has a doctor or other health professional ever talked to you or your child about how to recognize early signs or symptoms of an asthma episode? Has a doctor or other health professional ever taught you or your child what to do during an asthma attack? Do you or your child have an asthma action plan?, skip next question Do you or your child use an asthma action plan? Do you or your child know what a peak flow meter is? Has a doctor or other health professional ever taught you or your child how to use a peak flow meter to adjust your child s daily medications? Has a doctor or other health professional ever given you or your child an asthma action plan? Have you or your child ever taken a course or class on how to manage your child s asthma? Has your child ever used a prescription inhaler? Has a doctor or other health professional ever showed your child how to use the inhaler? Has a doctor or other health professional ever watched your child use the inhaler? In the last month (or past 30 days), how many days would you say you or your child had symptoms of asthma? 0 5 days 6 10 days days days days days In the last month (or past 30 days), how many days of school did you or your child miss because of asthma? 0 5 days 6 10 days days days days days

5 Summary of Findings:

6 In-Home Environment Assessment Form (Pg 1) For Initial Visit (mm/dd/year): For Follow-up Visit (mm/dd/year): Intervention Immediate Medical Intervention Must check one for each identified What was applied / Date applied? (mm/dd/yy) Was the implemented? If no, provide at least one reason Was a new Referred to PCP or Linked the Member to a PCP Name of the PCP given to the member. Cleaning/ Housekeeping Techniquesincluding safe products Garbage Control Pest/Roach/ Rodent Managementincluding safe products Smoking Cessation Program

7 In-Home Environment Assessment Form (Pg 2) For Initial Visit (mm/dd/year): For Follow-up Visit (mm/dd/year): Interventions Smoker s Quitline Must check one for each identified What was applied / Date applied? (mm/dd/yy) Was the implemented? If no, provide at least one reason Was a new Nicoderm/ Nicorette/ Other Moisture Control Asthma Self- Management Educationtrigger mitigation Asthma Self- Management Educationusing asthma action plan, controlling symptoms, and proper medication use.

8 In-Home Environment Assessment Form (Pg 3) For Initial Visit (mm/dd/year): For Follow-up Visit (mm/dd/year): Interventions Referral to Another Agency Must check one for each identified What was applied / Date applied? (mm/dd/yy) Was the implemented? If no, provide at least one reason Was a new What was the reason for the referral? Name of the referral source. Sources used to create this assessment tool: BRFSS Asthma Callback Survey (PA Bureau of Health Statistics and Research), Form ID: Healthy Neighborhoods Form 10 (NY Department of Health), Follow-up Home Assessment Form (Community Asthma Prevention Program of Philadelphia), and Asthma Home Environment Checklist (Environmental Protection Agency). Huber 2.1

Asthma Triggers. It is very important for you to find out what your child s asthma triggers are and learn ways to avoid them.

Asthma Triggers. It is very important for you to find out what your child s asthma triggers are and learn ways to avoid them. Asthma s It is very important for you to find out what your child s asthma triggers are and learn ways to avoid them. With asthma, your child s airways are very sensitive. Things, called triggers, may