6 Months Visit Packet Lead Risk Questionnaire DOWNLOAD PDF 6 Months Visit Packet Lead Risk Questionnaire Purpose:To identify children who need to be tested for lead exposure.Instructions• If Yes or Don’t Know, test the child immediately.• You may administer a blood lead test instead of using this questionnaire.• For more information, contact the Texas Childhood Lead Poisoning Prevention Program at: 1-800-588-1248.Patient’s Name:DOB:Medicaid #:Patient’s Name:Administered by:DateEmail AddressQuestions1. Does your child live in or visit a home, day-care or other building built before 1978?Yes or Don’t KnowNo2. Does your child live in or visit a home, day-care or other building with ongoing repairs or remodeling?Yes or Don’t KnowNo3. Does your child eat or chew on non-food things like paint chips or dirt?Yes or Don’t KnowNo4. Does your child have a family member or friend who has or did have an elevated blood lead level?Yes or Don’t KnowNo5. Is your child a newly arrived refugee or foreign adoptee?Yes or Don’t KnowNo6. Does your child come in contact with an adult whose job or hobby involves lead exposure?Yes or Don’t KnowNoExamples• House construction or repair• Battery manufacturing or repair• Burning lead-painted wood• Automotive repair shop or junk yard• Going to a firing range or reloading bullets• Chemical preparation• Valve and pipe fittings• Brass/copper foundry• Refinishing furniture• Making fishing weights• Radiator repair• Pottery making• Lead smelting• Welding7. Does your family use products from other countries such as pottery, health remedies, spices, or food?Yes or Don’t KnowNoExamples• Traditional medicines such as Ayurvedic, greta, azarcón, alarcón, alkohl, bali goli, coral, ghasard,liga, pay-loo-ah, and rueda• Cosmetics such as kohl, surma, and sindor• Imported or glazed pottery, imported candy, and imported nutritional pills other than vitamins.• Foods canned or packaged outside the U.S.Texas Childhood Lead Poisoning Prevention Program ▪ Texas Department of State Health ServicesPO BOX 149347 ▪ Austin, TX 78714-9347 ▪ 1-800-588-1248 ▪ www.dshs.texas.gov/leadSubmit form
