EPSDT Care for Kids Newsletter

EPSDT Care for Kids Newsletter

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Spring 2006

Iowa Department of Public Health
Childhood Lead Poisoning Risk Questionnaire

Date __________________________

Name __________________________________________ Date of Birth ______________

Address ____________________________________________________________________
Street Apt. # City State ZIP

Yes and Don't know = High Risk

If the answer to any of these questions is “yes," the child is considered to be at high risk for lead poisoning and must be screened according to the high-risk screening schedule.

If the parent does not know the answer to a question, assume that the answer is “yes.”

Review this questionnaire at each regular visit. Enter the date each time you review the questionnaire, and note any changes to the answers.

Yes/No	Questions *Yes* and Don't know = High Risk	Notes
Yes No	Has your child ever lived in or regularly visited a house built before 1960? (Examples: home, daycare center, babysitter, relative's home)
Yes No	Have you noticed any peeling or chipping paint in or around a pre-1960 house that your child has lived in or regularly visited?
Yes No	Has the pre-1960 home that your child lived in or regularly visited been remodeled or renovated by: Stripping, sanding, or scraping paint on the inside or outside of the house Removing walls and/or tearing out lath and plaster
Yes No	Does your child eat non-food items such as dirt?
Yes No	Have any of your other children or their playmates had blood lead levels of 15 µg/dL or more?
Yes No	Does your child live with or frequently come in contact with an adult who works with lead on the job or in a hobby? (Examples: painter, welder, foundry worker, old home renovator, shooting range worker, battery plant worker, battery recycling worker, ceramics worker, stained glass worker, sheet metal worker, scrap metal worker, plumber)
Yes No	Does your child live near a battery plant, battery recycling plant, or lead smelter?
Yes No	Do you give your child any home or folk remedies? (Examples: Azarcon, greta, pay-loo-ah)
Yes No	Does your child eat candy that comes from Mexico or is purchased from a Mexican grocery store?
Yes No	Has your child ever lived in Mexico, Central America, South America, Africa, Asia, or eastern Europe, or visited one of these areas for a period of longer than two months?

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