Pediatric Environmental History Initiative

History Forms

The Pediatric Environmental History Form (PDF, 4 pages) (Also available en Espanol) consists of 2 questionnaires:

• The Screening Environmental History (PDF, 1 page) (Also available en Espanol), designed to be administered by the primary health care provider in less than five minutes in order to capture most of the common environmental exposures to children;
• Additional Categories and Questions to Supplement the Screening Environmental History (PDF, 3 pages) (Also available en Espanol), which provides further categories and questions for the health care provider to ask if a positive response is given to one or more of the screening questions.

Environmental History Form for Pediatric Asthma Patient (Also available en Espanol):
Developed as an initial intake tool specifically for children already diagnosed with asthma.