Priority Pediatrics PC

Lead Risk Assessment Questionnaire

Please register on my Updox Portal BEFORE starting this questionnaire, if you have not already previously registered, so that your work can be saved and completed in more than one seating if needed. Once you are registered on the Portal, you will be able to retrieve past sent forms and resend if needed. Also do NOT use your BACK Button or REFRESH, or you will lose all your Form information and need to start over. When completed, click SEND and the form will come securely to me. Thank you. Dr. T

Name of Person Providing Information and relationship to patient: * Name of Patient: * Date of Questionnaire completion: * 1. Since your last lead risk assessment, have there been any significant changes in day care, your home, hobbies, or occupation? * If Yes, please elaborate: 2. Does your child exhibit pica (eat dirt)? * 3. Does your child live in or frequently (once a week or more) visit a house built before 1978? * 4. Was your child's day care center/preschool/baby sitter's home built before 1978? * 5. Does your child live in a house built before 1978 with recent, ongoing or planned renovations or remodeling? * 6. Does your your child's house or daycare have peeling or chipping paint inside or outside? * 7. Is there old furniture or painted woodwork in your home or daycare that your child can chew on (crib, bannister)? * 8. Does your child live or frequently visit a home near a heavily traveled major highway where soil and dust might be contaminated with lead? Is your child's day care near a busy similar roadway? * 9. Does your child regularly eat from ceramic or pewter dishes? Is food stored in tin cans, ceramic ware, or pottery? * 10. Have any of your children or their playmates had lead poisoning? * If any of the above answered Yes, please elaborate here: 11. Think about the occupations of all household members and frequent visitors to your home? Does your child frequently come in contact with an adult who works with lead? Examples are construction, welding, pottery or other trades practiced in your community. Does anyone in the household have a hobby which uses lead? Examples are fishing weights, casting ammunition, toy soldiers, making stained glass, making pottery, refinishing furniture, burning lead-painted wood. * If #11 answered Yes, please elaborate here: 12. Does your child live near a lead smelter, battery recycling plant, or other industry likely to release lead? Does your child live near a source of current industrial pollution or on the site of the old industry or mining? * If #12 answered Yes, please elaborate here: 13. Do you give your child any home or old remedies which may contain lead? Examples: Azarcon, Kohl, Alkohi, Bali Goli, Coral, Ghasard, Greta, Ligo, Pay-loo-ah, and Rueda (none are legal in the U.S.). * If #13 answered Yes, please elaborate here: 14. Does your home's plumbing have lead pipes or copper with lead soldiered joints? Have there been any plumbing repairs or fixtures added within the last 5 years? * If #14 answered Yes, please elaborate here:

If the above questions are answered NO, your child is VERY unlikely to have been exposed to environmental lead and requires no lead testing.

If you have answered any of the above questions YES, please tell me more and explain your answers. Your child may need a screening blood test to measure lead exposure. Please talk to the doctor about your child's risk of lead exposure.

Thank you for completing this questionnaire and forwarding it to the doctor. You may want to save the completed questionnaire to your hard drive before sending, in case you want to resend if it is not received by Dr. T.