Questionnaire for Lead Poisoning in Pregnant Women
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County of Residence
Please answer each of the following questions.
Have you ever had a high blood lead level?
Have you spent any time outside of the United States in the past 12 months?
Do you use any pottery, remedies, spices, foods, candies or makeup that are not sold in a regular drug store or are homemade, but are sent to you from another country?
Sometimes pregnant women have the urge to eat nonfood items such as clay, soil, plaster, paint chips, or crushed pottery. Do you ever eat any of these things, even accidentally?
This past year, have there been any major renovations in your home that involved sanding or scraping?
Was your home built before 1978?
Do you or others in your household have a job or a hobby that involves possible lead exposure, such as home renovation or working with stained glass, ceramics, jewelry, auto repair or battery manufacturing?
Based on the results of a laboratory test, have you been told there's lead in your home's water?
Have any of your children had an elevated blood lead level (>5ug/dL)?
Should be Empty: