Childhood Lead Risk Questionnaire

Reminder: ALL children ages 9-12 months and again at 24 months of age MUST receive a blood lead test.

PURPOSE: This questionnaire helps identify children who may be at risk for lead exposure.

HOW TO USE: Check the appropiate answer for each question

If any answer of "Yes" or "Don't Know" → perform a blood lead test today
If ALL answers are "No" → No test needed today, re-evaluate at next visit.

Today's Date

Date of last lead test (if known):

Child's Name

Age

Birthdate

RESPOND TO THE FOLLOWING QUESTIONS BY CHECKING THE APPROPRIATE ANSWER.

1. Is the child under 3 years of age and did they miss either their 9-12 month or 24 month test? - OR- Is the child 3-6 years of age and have they never been tested?

Yes No Don't Know

SINCE THE CHILD'S LAST EVALUATION, HAS THE CHILD:

2. Moved to a home or begun to regularly visit a building built before 1978?

Yes No Don't Know

3. Been exposed to repairs, repainting, or renovations of a building/home built before 1978?

Yes No Don't Know

4. Frequently been around anyone whose job or hobby exposes them to lead (e.g. construction, painting, plumbing, battery work, mining, firearms, or fish weights)?

Yes No Don't Know

5. Been frequently exposed to any traditional or cultural medicines, spices, candy, toys, pottery, powders or cosmetics (such as Kohl, Kajal, Surma, Sindoor or Kumkum) from other countries?

Yes No Don't Know

6. Spent any significant time outside the U.S.?

Yes No Don't Know

7. Been in a home, school, or childcare setting where the water tested at or above 5ppb for lead?

Yes No Don't Know

8. Lived near an active lead smelter, battery recycling plant, or another industry likely to release lead, or does your child live near a heavily traveled road where soil and dust may be contaminated with lead?

Yes No Don't Know

It is always appropriate to obtain a diagnostic blood lead test when a child is symptomatic or a potential exposure to lead has 8been identified, regardless of the child's age.

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

Signature of Doctor/Nurse

Date

Your information will be encrypted.