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Lead Poisoning Risk Assessment
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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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    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
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    Thank you for completing our questionnaire.

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