Patient Health Risk Screening

FOR PARENT/GUARDIAN TO FILL OUT

Patient Name:

DOB:

PLEASE CHECK ALL THAT APPLY. INITIAL/DATE AT THE BOTTOM ONCE EACH VISIT.

Anemia Screen (for all children):

Consumes a diet low in iron

Child has limited access to food

Child with history of iron-deficiency anemia

Child has special health care needs

Child takes medicine that inhibits iron absorption

Family has limited income (eligible for Medicaid or WIC)

Migrant or recently arrived immigrant

Drinks more than 24 ounces of whole milk per day

Lead Screen (for 6 years and under):

Child lives in or regularly visits a home or childcare facility built before 1978 that is being renovated or was renovated within the past 6 months

Child lives in or regularly visits a home or childcare facility built before 1950

Child lives in or regularly visits a house or other structure in which one or more persons have elevated blood lead levels

Child lives with an adult whose job or hobby involves working with lead Your child’s school or daycare requires it (ex. school or care in Washington

Child resides in high zip code area (see list at front desk)

Child receives services with Medicaid or WIC

Child lives near an active lead smelter, battery recycling plant, or other industry likely to release lead

In addition, do you suspect an exposure for your child?

Tuberculosis Infection Risk (all children):

Lived in high prevalence country or extensive travel in area with high prevalence

Exposure to tuberculosis or to a high-risk adult

Visits nursing homes or correctional facilities

Chronic illness with increased risk for infection (HIV, malignancy, diabetes, etc.)

Your child’s school or daycare requires it

Medically underserved

Homelessness or residence in congregate living

Fluoride (all children 6 months to 14 years)

Only breastfed and not drinking water

Using bottled water only (for mixing formula or to drink alone)

Home with well water

School with well water and home with well water (ex. Clifton Elementary School)

Hyperlipidemia (all children older than 2 years)

Does a parent take cholesterol medicine

Does a sibling have high cholesterol

Has a parent or sibling had a heart attack or stroke

Has a grandparent had a heart attack or stroke under 60 years old

CHECK HERE IF NONE OF THE ABOVE APPLIES.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

Date of Appointment

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