Childhood Lead Risk Questionnaire
Evaluation for lead poisoning
Parent's Name
(Required)
First
Last
Child's Name
(Required)
First
Last
Age
(Required)
Birthdate
(Required)
MM slash DD slash YYYY
Respond to the following questions by selecting the appropriate answer.
1. Does your child live in or visit a home, day-care or other building built before 1978?
(Required)
Yes
No
Don't Know
2. Does your child live in or visit a home, day-care or other building with ongoing repairs or remodeling?
(Required)
Yes
No
Don't Know
3. Does your child eat or chew on non-food things like paint chips or dirt?
(Required)
Yes
No
Don't Know
4. Does your child have a family member or friend who has or did have an elevated blood lead level?
(Required)
Yes
No
Don't Know
5. Is your child a newly arrived refugee or foreign adoptee?
(Required)
Yes
No
Don't Know
6. Does your child come in contact with an adult whose job or hobby involves lead exposure? Examples:
(Required)
• House construction or repair
• Battery manufacturing or repair
• Burning lead-painted wood
• Automotive repair shop or junk yard
• Going to a firing range or reloading bullets
• Chemical preparation
• Valve and pipe fittings
• Brass/copper foundry
• Refinishing furniture
• Making fishing weights
• Radiator repair
• Pottery making
• Lead smelting
• Welding
Yes
No
Don't Know
7. Does your family use products from other countries such as pottery, health remedies, spices, or food? Examples:
(Required)
• Traditional medicines such as Ayurvedic, greta, azarcón, alarcón, alkohl, bali goli, coral, ghasard, liga, pay-loo-ah, and rueda
• Cosmetics such as kohl, surma, and sindor
• Imported or glazed pottery, imported candy, and imported nutritional pills other than vitamins.
• Foods canned or packaged outside the U.S.
Yes
No
Don't Know
Source: Texas Childhood Lead Poisoning Prevention Program ▪ Texas Department of State Health Services ▪ www.dshs.state.tx.us/lead
English
English
Spanish
English 
Spanish