4 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:

Date

Questions

1. Does your child live in or visit a home, day-care or other building built before 1978?Yes or Don’t KnowNo

2. Does your child live in or visit a home, day-care or other building with ongoing repairs or remodeling?Yes or Don’t KnowNo

3. Does your child eat or chew on non-food things like paint chips or dirt?Yes or Don’t KnowNo

4. Does your child have a family member or friend who has or did have an elevated blood lead level?Yes or Don’t KnowNo

5. Is your child a newly arrived refugee or foreign adoptee?Yes or Don’t KnowNo

6. Does your child come in contact with an adult whose job or hobby involves lead exposure?Yes or Don’t KnowNo

Examples

• 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
• Welding

7. Does your family use products from other countries such as pottery, health remedies, spices, or food?Yes or Don’t KnowNo

Examples

• 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 Services

PO BOX 149347 ▪ Austin, TX 78714-9347 ▪ 1-800-588-1248 ▪ www.dshs.texas.gov/lead