Lead Screening Questionnaire

Please correct the errors described below.

Todays Date:

Please answer all of the questions below. This will help the doctor decide if your child needs a special blood test.

1) Does your child live in or regularly visit an old house with peeling or chipped paint built before 1960? This might include a day care, preschool, babysitter, or relative’s house

Yes No

2) Does your child have a playmate, relative, brother, or sister who is being treated for lead poisoning?

Yes No

3) Does your child live with an adult or frequently come in contact with an adult whose work or hobby involves exposure with lead? (Example are construction, wielding, pottery, brass/foundry, auto repair shops)

Yes No

4) Does your child live near a lead smelter, battery recycling plant, or other industry likely to release lead? (such as pottery or valve and pipe fitting plant)

Yes No

5) Do you give your child any home or folk remedies that may contain lead?

Yes No

6) Does your child live near a heavily traveled major highway where soil or dust may be contaminated with lead?

Yes No

7) Does your home plumbing have lead pipe or copper with lead solder joints?

Yes No

8) Does your child eat food, drink juice, or punch that has been stored or cooked in pottery from Mexico?

Yes No

9) Do you have any questions about this survey for your doctor?

Yes No

If you answered yes to any of the above questions please be sure to talk with your doctor today during your child’s examination

Child’s Name:

Date of Birth:

AHCCCS ID#:

Your information will be encrypted.

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