Childhood Lead Risk Questionnaire
Based upon IL Dept of Public Health form IOCI 15-678, 4/2015
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Patient Name
*
First Name
Last Name
Date of Birth
*
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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
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TB Risk Assessment
IL Dept of Public Health criteria
Does this child have any symptoms of TB (cough, fever, night sweats, loss of appetite, weight loss, or fatigue) or an abnormal chest X-ray?
*
Yes
No
In the last two years, has the child lived with or spent time with someone who has been sick with TB?
*
Yes
No
Was the child born in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East?
*
Yes
No
Has the child lived or travelled in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East for more than one month?
*
Yes
No
Have any members of the child’s household come to the United States from another country?
*
Yes
No
Is the child exposed to a person who is: currently in jail, has been in jail in the past five years, has HIV, is homeless, lives in a group home, uses illegal drugs, or is a migrant farm worker?
*
Yes
No
Does the child have any history of immunosuppressive disease or take medications that might cause immunosuppression?
*
Yes
No
Parent/guardian/adult patient
*
First Name
Last Name
Signature
*
Clear
Submit
Should be Empty: