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Interview Sheet Company Name:_________________________________________________File Number:____________________ Address:______________________________________________________________________________________ Occupant/Employee Name:________________________________Work Location:___________________________ Completed by:_______________________________Title:_________________________Date:_________________ SYMPTOMS What kind of symptoms or discomfort are you experiencing?
Are you aware of other people with similar symptoms or concerns? Yes___________ No___________
If so, what are their names and locations?____________________________________________________________ ____________________________________________________________________________________________ Do you have any health conditions that may make you particularly susceptible to environmental problems? Contact lenses - Chronic cardiovascular disease - Undergoing chemotherapy or radiation therapy Allergies - Chronic respiratory disease - Immune system suppressed by disease or other causes Chronic neurological problems TIMING When did your symptoms start?
When are they generally worst?
Do they go away? If so, when?
Have you noticed any other events (such as weather events, temperature or humidity changes, or activities in the building) that tend to occur around the same time as your symptoms?
Interview Sheet Location Where are you when you experience symptoms or discomfort?
Where do you spend most of your time in the building?
ADDITIONAL INFORMATION Do you have any observations about building conditions that might need attention or might help explain your symptoms (e.g., temperature, humidity, drafts, stagnant air, odors)?
Have you sought medical attention for your symptoms?
Do you have any other comments?
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