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Lead Exposure Questionnaire

Please answer these questions with: Yes, No, or Don’t Know. The answers will help you and your health care provider decide if you or your child needs a blood test for lead.

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Question 1 of 13

1) Does your child or you live in, or regularly visit (for daycare or babysitting), a house built before 1950? Older houses may have lead-based paint, which breaks down into dust that can be swallowed or inhaled by your child.

A

Yes

B

No

C

Don't Know

Question 2 of 13

2) Does your child or you live in or regularly visit a house that has recently been remodeled? Remodeling in an older house, or even one built as late as 1978, can create dust that contains lead, if lead-based paint is present.

A

Yes

B

No

C

Don't Know

Question 3 of 13

3) Does any other child of yours or a child of a relative or friend have an elevated blood lead level?

A

Yes

B

No

C

Don't Know

Question 4 of 13

4)  Does your child live with or regularly visit an adult whose work or hobby uses lead? Or do you work or have a hobby that uses lead?

A

Yes

B

No

C

Don't Know

Question 5 of 13

5) Do you (or any family members, or a curandera or sobador) give your child orange, red, or yellow powder such as Greta or Azarcon, or use “Navajo” clay for stomach ache, nausea, and diarrhea?

A

Yes

B

No

C

Don't Know

Question 6 of 13

6) Do you use Kohl, Alkohl, or Surma on you or your child’s skin? Or use traditional Middle Eastern, Oriental, and Ayurevedic preparations?

A

Yes

B

No

C

Don't Know

Question 7 of 13

7) Does your home have imported plastic/vinyl mini-blinds? Some imported plastic mini-blinds made before 1996 have lead in them

A

Yes

B

No

C

Don't Know

Question 8 of 13

8) Does your child or you eat, put things in his/her mouth, or chew on things that aren’t food? Dirt, wood (especially window sills), paint chips, jewelry, shell casings, fishing sinkers, lead shot, shoes, or socks can have lead or lead dust on/in them

A

Yes

B

No

C

Don't Know

Question 9 of 13

9)  Do you use imported pottery for cooking, storing, or serving food? Some Mexican, Chinese, and Italian potteries have lead in the glaze, which can get into the food.

A

Yes

B

No

C

Don't Know

Question 10 of 13

10) Does your child or you live or play near a junkyard, dump, mine, smelter, busy street, or highway? These places can have lead dust in the air or in the dirt. Even if the smelter or mine is closed, lead can still be in the dirt.

A

Yes

B

No

C

Don't Know

Question 11 of 13

11) Have you or your child been to Mexico, Central or South America, Asian countries (i.e., China or India), or any country where exposure to lead from certain items could have occurred (for example, cosmetics, home remedies, folk medicines or glazed pottery)?

A

Yes

B

No

C

Don't Know

Question 12 of 13

12) At any time, have you or your child lived near a factory where lead is used (for example, a lead smelter or a paint factory)?

A

Yes

B

No

C

Don't Know

If you answered Yes to any of these questions, you or your child may be at risk for being exposed to lead! You or your child’s health care provider will need to order a blood test.

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