Lead Screening Questionnaire (only fill out if your child is 2 years old or younger)

Canyon Pediatrics > Lead Screening Questionnaire (only fill out if your child is 2 years old or younger)
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1) Does your child live in or regularly visit an old house with peeling or chipped paint built before 1960? This might include a day care, preschool, babysitter, or relative’s house
2) Does your child have a playmate, relative, brother, or sister who is being treated for lead poisoning?
3) Does your child live with an adult or frequently come in contact with an adult whose work or hobby involves exposure with lead? (Example are construction, wielding, pottery, brass/foundry, auto repair shops)
4) Does your child live near a lead smelter, battery recycling plant, or other industry likely to release lead? (such as pottery or valve and pipe fitting plant)
5) Do you give your child any home or folk remedies that may contain lead?
6) Does your child live near a heavily traveled major highway where soil or dust may be contaminated with lead?
7) Does your home plumbing have lead pipe or copper with lead solder joints?
8) Does your child eat food, drink juice, or punch that has been stored or cooked in pottery from Mexico?
9) Do you have any questions about this survey for your doctor?

If you answered yes to any of the above questions please be sure to talk with your doctor today during your child’s examination

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