Does your child need a lead test?
Child's Date of Birth
(FOR OFFICE ONLY) - MRN #
Does your child live in or regularly visit a building built before 1978 with potential lead exposures, such as peeling or chipping paint, recent or ongoing renovation or remodeling , or high levels of lead in the drinking water?
Has your child spent any time outside the United States in the past year?
Does your child live or play with a child who has an elevated blood lead level?
Does your child have developmental disabilities, put nonfood items in their mouth, or peel or disturb painted surfaces?
Does your child have frequent contact with an adult who may bring home traces of lead from a job or hobby such as: house painting, plumbing, renovation, construction, auto repair, welding, electronics repair, battery recycling, lead smelting, jewelry, stained glass or pottery making, fishing (weights, "sinkers"), firearms, or collecting lead or pewter figurines?
Does your family use traditional medicines, health remedies, cosmetics, powders, spices, or food from other countries?
Does your family cook, store, or serve food in crystal, pewter, or pottery from other countries?
Did your child miss a lead test?New York State requires al children to be tested for lead at age 1 and again at age 2.
If yo answered "YES" or "NOT SURE" to any of these questions, your child may need a blood lead test.
Lead is a concern, especially for childrenunder age 6. It's important for you and your health care provider to know yor child's blood lead level.
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