Lead Risk Questionnaire 5 DOWNLOAD PDF Lead Risk Questionnaire 5 Patient’s Name:DOBMedicaid #:Provider’s Name:Administered by:DateEmail AddressDoes your child live in or visit a home, day-care or other building built before 1978?Yes or Don’t KnowNoDoes your child live in or visit a home, day-care or other building with ongoing repairs or remodeling?Yes or Don’t KnowNoDoes your child eat or chew on non-food things like paint chips or dirt?Yes or Don’t KnowNoDoes your child have a family member or friend who has or did have an elevated blood lead level?Yes or Don’t KnowNoIs your child a newly arrived refugee or foreign adoptee?Yes or Don’t KnowNoDoes 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 Lead smelting 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 Foods canned or packaged outside the U.S. Submit form
