Lead Risk Questionnaire

Lead Risk Questionnaire

Storybook Pediatrics Lead Risk Questionnaire

(MM/DD/YYYY)
(MM/DD/YYYY)

Current Contact Information

Primary email with verification
Other email with verification
1. Does the child live in or often visit a house that may have been built before 1978? *
2. Does the child live in or often visit a house that is being remodeled or is having paint removed? *
3. Does the child live with or often visit another child that has an elevated blood lead level? *
4. Does the child live with anyone that works at a job where lead may be found or has a hobby that uses lead? *
5. Does the child chew on or eat non- food items like paint chips or dirt? *
6. Does the child live near an active lead smelter, battery recycling plant, or other industry likely to release lead? *
7. Does the child receive medicines such as greta, azarcon, kohl, or pay-loo-ah? *
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