Childhood Lead + TB Risk Questionnaires

Today’s Date

Date

Patient Name *

First Name Last Name

Date of Birth *

Month Day Year

ZIP Code *

Is this child eligible for or enrolled in Medicaid, Head Start, All Kids or WIC? *

Yes No Don’t know

Does this child have a sibling with a blood lead level of 10 mcg/dL or higher? *

Yes No Don’t know

Does this child live in or regularly visit a home built before 1978? *

Yes No Don’t know

In the past year, has this child been exposed to repairs, repainting, or renovation of a home built before 1978? *

Yes No Don’t know

Is this child a refugee or an adoptee from any foreign country? *

Yes No Don’t know

Has this child ever been to Mexico, Central or South America, Asian countries (i.e. China or India), or any country where exposure to lead from certain items could have occurred (e.g. cosmetics, home remedies, folk medicines, or glazed pottery? *

Yes No Don’t know

Does this child live with someone who has a job or hobby that may involve lead (e.g. jewelry making, building renovation or repair, bridge construction, plumbing, furniture refinishing, or work with car batteries or radiators, lead solder, leaded glass, lead shots, bullets, or lead fishing sinkers)? *

Yes No Don’t know

At any time, has this child lived near a factory where lead is used (e.g. a lead smelter or paint factory)? *

Yes No Don’t know

Does this child live in a high-risk ZIP code (see list of high-risk ZIP codes below)? *

Yes No Don’t know

Please refer to this list and determine if your child lives in a high-risk ZIP code

Childhood Lead Risk Questionnaire

TB Risk Assessment