Lead Risk Questionnaire Lead Risk Questionnaire Lead Risk Questionnaire Email to receive your copy (Optional) Confirm Email to receive your copy (Optional) Enter a confirmation email address. Date * (MM/DD/YYYY) Child’s Name * DOB * (MM/DD/YYYY) Street * City * State * Zip * Current Contact Information Mom’s Phone Dad’s Phone 1. Primary Email Confirm 1. Primary Email Enter a confirmation email address. 2. Other Email Confirm 2. Other Email Other email with verification Questions 1. Does the child live in or often visit a house that may have been built before 1978? * Yes, or I don’t know No 2. Does the child live in or often visit a house that is being remodeled or is having paint removed? * Yes, or I don’t know No 3. Does the child live with or often visit another child that has an elevated blood lead level? * Yes, or I don’t know No 4. Does the child live with anyone that works at a job where lead may be found or has a hobby that uses lead? * Yes, or I don’t know No 5. Does the child chew on or eat non- food items like paint chips or dirt? * Yes, or I don’t know No 6. Does the child live near an active lead smelter, battery recycling plant, or other industry likely to release lead? * Yes, or I don’t know No 7. Does the child receive medicines such as greta, azarcon, kohl, or pay-loo-ah? * Yes, or I don’t know No Parent or Legal Guardian Signature signature keyboard Clear If you are human, leave this field blank. Submit
