Childhood Lead + TB Risk Questionnaires

Childhood Lead Risk Questionnaire

Based upon IL Dept of Public Health form IOCI 15-678, 4/2015
Today’s Date

MonthDayYear
Date
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
ZIP Code*
Is this child eligible for or enrolled in Medicaid, Head Start, All Kids or WIC?*

YesNoDon’t know
Does this child have a sibling with a blood lead level of 10 mcg/dL or higher?*

YesNoDon’t know
Does this child live in or regularly visit a home built before 1978?*

YesNoDon’t know
In the past year, has this child been exposed to repairs, repainting, or renovation of a home built before 1978?*

YesNoDon’t know
Is this child a refugee or an adoptee from any foreign country?*

YesNoDon’t know
Has this child ever been to Mexico, Central or South America, Asian countries (i.e. China or India), or any country where exposure to lead from certain items could have occurred (e.g. cosmetics, home remedies, folk medicines, or glazed pottery?*

YesNoDon’t know
Does this child live with someone who has a job or hobby that may involve lead (e.g. jewelry making, building renovation or repair, bridge construction, plumbing, furniture refinishing, or work with car batteries or radiators, lead solder, leaded glass, lead shots, bullets, or lead fishing sinkers)?*

YesNoDon’t know
At any time, has this child lived near a factory where lead is used (e.g. a lead smelter or paint factory)?*

YesNoDon’t know
Does this child live in a high-risk ZIP code (see list of high-risk ZIP codes below)?*

YesNoDon’t know
Please refer to this list and determine if your child lives in a high-risk ZIP code

Childhood Lead Risk Questionnaire

TB Risk Assessment