Lead Poisoning Risk Assessment

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Lead Poisoning Risk Assessment
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Your information is secure
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INSTRUCTIONS:

This questionnaire is for use with children under 6 years old. Please administer this questionnaire at every annual checkup.

A “yes” or “unknown” response to any question indicates the child is at risk for lead poisoning and should receive a blood test and appropriate follow-up.

Every Medicaid patient requires a blood test at 12 and 24 months of age, and between the ages of 36 months and 72 months of age if they have not been previously screened for lead poisoning.
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Name of your child?
First Name
Middle Name
Last Name
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Your child's date of birth
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1. Does your child live in or regularly visit (once a week or more) any house or building built before 1978?
YesNo
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2. Does your child live in or regularly visit any house or building that has recently undergone renovation or contains vinyl mini blinds, lead pipes,pipes with lead solder joints, or had metal pipes replaced or repaired within the last five years?
YesNo
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3. Does your child have a mother, sibling or playmate that has or did have lead poisoning?
YesNo
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4. Does your child frequently come into contact with an adult whose job or hobby involves exposure to lead? Occupations: building renovation • battery factory or recycling • auto or radiator repair • highway bridge sandblasting or painting • welding metal structures • wire cable cutting Hobbies: refinishing furniture • home renovation • casting bullets • auto battery or radiator repair • making stained glass ceramics, toy soldiers, dive weights, or fishing weights
YesNo
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5. Does your child eat food or drink fluids that were stored in leaded crystal,imported ceramic or pewter dishes?
YesNo
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6. Does your child have contact with cosmetics, kohl, candies, spices,jewelry, ceramic dishware and home (or folk) remedies not made in the United States?
YesNo
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7. Does your child play in loose soil, near a busy road or near any industrial sites such as a battery recycling plant, junk yard or lead smelter?
YesNo
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8. Have you ever seen your child eat dirt or his mouth on painted surfaces,paint chips, toy jewelry, or vinyl mini blinds?
YesNo
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9. Has your child recently visited another country for an extended period of time, lived in foster care home or in a country other than the United States?
YesNo
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Would you like to share any observations of your child's behavior with the doctor?
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Your Name
First Name
Middle Name
Last Name
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Your relationship with the patient
Mother
Father
Grandmother
Grandfather
Legal Guardian
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Signature* This field is required
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Thank you for completing our questionnaire.
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Was this electronic from easy?
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