Lead Risk Questionnaire

Date *

(MM/DD/YYYY)

Child’s Name *

DOB *

(MM/DD/YYYY)

Street *

City *

State *

Zip *

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