For Pollutant Standards Index (PSI*): See local phone book for EPA reporting station. At http://www.scorecard.org/ use your zip code to check health effects of pollution in your neighborhood.

For a few days, fill in what you can to become aware of what may be affecting you. 

Check or circle all symptoms such as: coughing, sneezing, wheezing, chest tightness, shortness of breath, headache, smarting eyes, heartburn, clogged ears, ear ache, clogged nose, blurred vision, chills, fatigue, indecision ("mental fog"), disorientation, insomnia, anxiety, groggy, crave salt and/or sugar, other:

Check or circle exposure to fragrances: air fresheners/room deodorizers; perfume/cologne (list brand name if known); fragrance personal care product such as shampoos and hair conditioners; deodorants, lotions, hair sprays and gels, shaving cream, foam or gel, after-shave lotion or cologne;  anti-bacterial soaps; detergents, dishwashing/laundry; fabric softeners, liquid/dryer sheets; carpet and upholstery shampoo. See: Julia Kendall's (1935-1997) information on the composition and health effects of fragrances.  Then go to the home page and search "AVOID" for what the ALA and AMA say about triggers.

Check or circle all recurring indoor factors: pesticides, disinfectants, chlorine, dust, dander, mold, gas range, computer, fax, copier, stale air, second hand smoke, carpeting, roaches, news print, formaldehyde, fresh paint or varnish, musk, natural latex, indoor renovation (dust, mold), recycled air in closed buildings, other:

Check or circle all recurring local outdoor conditions: construction, road repair, fire, barbecue, industry, expressway, airport, hot asphalt, dry cleaner, laundromat, hospital, gas station, other:

On back of paper, note date and describe time, circumstances (inside or outside, sedentary or exercising), and what you did to alleviate your symptoms: e.g. removed self from situation, put on a mask (what kind), took medication (be specific), closed windows and turned on air conditioning.

*In many locations the PSI reports only the highest pollutant. To keep track, indicate the number and critical pollutant for each region which may affect you: Ozone (O₃); Particulate Matter (PM); Sulfur Dioxide (SO₂); Carbon Monoxide (CO); Nitrogen Dioxide (NO₂). Combined pollutants and high humidity may cause eyes to smart and may irritate nasal passages and lungs at "good" and "moderate" levels.

Free access material, developed April 1996, revised October 2, 2002. Prepared by Adrien J. Bledstein, courtesy of I Can Breathe! Air Filter Masks.