Lead Risk Questionnaire Lead Risk Questionnaire Storybook Pediatrics Lead Risk Questionnaire 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 Primary email with verification 2. Other Email Confirm 2. Other Email Other email with verification 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 Email to send my confirmation copy (if different from primary email address above) Confirm Email to send my confirmation copy (if different from primary email address above) Parent or Legal Guardian Signature Clear If you are human, leave this field blank. Submit