Follow-Up Lead Poisoning Questionnaire

Follow-Up Lead Poisoning Questionnaire
Date this questionnaire was completed

MonthDayYear
Date
The follow-up questions below serve as a tool to show that appropriate control measures have been implemented per ARM 37.114.546.
Name

Patient First NamePatient Last Name
DOB

MonthDayYear
Patient Date
Sex
Race
Ethnicity
Address

Patient Street Address

Street Address Line 2

Patient CityPatient State / Province

Patient Postal / Zip Code
YesNoUnknown
Date physician was contacted.

MonthDayYear
Date
YesNoUnknown
Date for re-testing.

MonthDayYear
Date

Rows	Yes	No	Unknown
Is the patient a child who attends daycare?
Is the patient enrolled in Medicaid?
Does the patient receive Women, Infants, and Children (WIC) Program Services?
Is the patient a child who has been placed in a home through the Foster System?
Does the patient live in or visit a home, daycare or other building built before 1978 with peeling or chipping paint, or with recent or ongoing renovation or remodeling?
Does the patient live in a rental property?
Does the patient live (or previously lived) in assisted housing or receive any financial assistance for housing (ex. Housing Choice Voucher, Project-Based Section 8, Public Housing)?
Does the patient eat, chew, or mouth non-food items such as paint chips, dirt, dust, or soil?
Is there a family member/friend who ever had an elevated blood level?
Should other household members be tested for elevated blood lead?
Is the patient a refugee, immigrant, or adopted from another country?

Country of Origin
Country of last residence (if different)
Glazed pottery makingSmelting or miningWelding or solderingLead fishing weights or luresBattery manufacturing or recyclingPainting (artistic, commercial, residential)Automotive repair or paintingLead ammunitions (ex. hunting, shooting sports, going to a firing range, or reloading bullets)Construction - renovation or repairEnvironmental remediation of hazardous materialsValve and pipe fittingBrass/copper fabrication (ex. foundry worker)Refinishing furnitureOther
Drinking water (pre-1986 household plumbing/fixture or a private well)Eating wild game that may have been harvested using leaded ammunitionImported dishes or cups. (ex. glazed pottery, ceramics, or metal)Spices or candy (ex. tamarind, plum, turmeric, chili, lozeena) or other foods canned or packaged outside of the United StatesTraditional home remedies or cosmetics (ex. Remedies - Azarcon or Greta, Ba-Baw-san, Ayruvedics, Pay-loo-ah; Cosmetics - Kohl, Surma, or Tiro)Products recalls or food alerts due to a lead hazard from the US Consumer Product Safety Commission, www.cpsc.gov/Recalls, or the US Food & Drug Administration, https://www.fda.gov/food/recalls-outbreaks-emergencies/alerts-advisories-safety-information.
Potential lead exposures not already indicated:
Additional people in the home that could be at risk:
If the exposure was identified through occupational medical monitoring, indicate the following: Industry (ex. mining), Occupation (ex. electrician), Employer, and Employer Contact Information.
Upload any photos of the lead exposure area, if applicable.

Cancelof
Sender's Email (ex. nurse.smith@publichealth.gov) *
example@example.com
Should be Empty: