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.