72 Month Forms

72 Month Screening Forms
Child's Name*

First Name Last Name
Child's Birthday*

MonthDay Year
Child's Gender

FemaleMale

Lead Exposure Risk Assessment Questionnaire for Children*

	Yes	No	Unsure
1. Does your child live in or regularly visit a building built before 1950? (This includes your home, a child care facility, preschool, or home of a babysitter or a relative, etc.)
a. Before 1978?
b. If yes to either, does the building have peeling or chipping paint or has it recently been renovated or remodeled?
2. Do the windows in the building have plastic non-glossy vinyl mini-blinds?
3. Has your family/child ever lived outside the United States? If see please list below.
4. Does your child have a sibling, housemate, friend, or playmate that has been diagnosed with or treated for lead poisoning?
5. Does your child play with brass (yellow-colored metal) keys?
6. Does your child eat non-food items (like dirt or paint chips)?
7. Does your child frequently come in contact with anyone whose job or hobby involves exposure to lead? (Jobs include house painting, plumbing, renovation, construction, auto repair, welding, electronics repair, jewelry or pottery making. Hobby examples include making stained glass or pottery, fishing, making or shooting firearms, and collecting lead or antique pewter figurines.)
8. Does your family use products from other countries such as health remedies, folk medicines, spices, candy or other foods, or store or serve food in leaded crystal, pottery or antique pewter?
9. Are there any smokers in the home?
10. Has your family travelled to any foreign countries within the past year?

Pediatric Oral Health Screening*

	Yes	No
a.) Primary caregiver(s) has had active dental decay in the past 12 months
b.) Older siblings with history of dental decay
c.) Continual use of bottle containing beverages other than plain water (nothing added).
d.) Child sleeps with bottle
e.) Frequent (greater than 3x/day total) candy, carbohydrate snacks, soda, sugared beverages, and fruit juice
f.) Medical risks: 1. Saliva-reducing meds (asthma, seizure, hyperactivity, etc.) 2. Developmental problems 3. History of anemia or iron therapy 4. Daily liquid meds

Notes (please use letter to identify what question is being addressed):
Should be Empty: