Marlborough Pediatrics

Gubbanna Kumar, MD

Carrie Streim, MD

QUESTIONNARE FOR HIGH RISK OF LEAD EXPOSURE

Name of child: ______Age: ______

Information provided by: ______Date: ______

Please circle the appropriate response.

  1. Does your child live in or regularly visit a house with peeling orYES NO

chipping paint built before 1960? (This could include a daycare

center, preschool, the home of a baby-sitter or a relative, etc.)

  1. Does your child live in or regularly visit a house built before 1960YES NO

with recent, ongoing or planned renovation or remodeling?

  1. Have any of your children or your children’s playmates beenYES NO

followed for, or treated for lead poisoning?

  1. Does your child live with an adult whose job or hobby involvesYES NO

exposure to lead (see list below)?

  1. Does your child live near an active lead smelter, battery recyclingYES NO

plant or other industry likely to release lead?

  1. Does your child live near a heavily traveled major highway whereYES NO

soil and dust may be contaminated with lead?

  1. Does your home’s plumbing have lead pipes or copper with leadYES NO

solder joints, or are you aware of any lead contamination in your

water supply from outdated plumbing?

Sources of lead exposure

Occupational / Environmental / Hobbies & Related Activities / Substance Use
Plumbers, pipe fitters / Lead containing paint / Glazed pottery making / Folk remedies
Lead miners / Leaded gasoline / Target shooting at ranges / “Health foods”
Rubber product manufacturers / Soil/dust near lead industry, roadways, lead-painted homes / Lead soldering (eg.electronics) / Cosmetics
Glass manufacturers / Plumbing leachate / Painting / Moonshine whiskey
Shipbuilders / Ceramic ware / Preparing lead shot / Gasoline “Huffing”
Printers / Preparing fishing sinkers
Plastic manufacturers / Stained-glass making
Lead smelters and refiners / Car or boat repair
Policemen / Home remodeling
Steel welders or cutters
Construction workers
Auto repairers
Gas station attendants
Battery manufacturers
Bridge reconstruction workers

This table was taken from US Department HHS, Agency for Toxic Substance and Disease Registry, Case Studies in Environ, Medicine: Lead Toxicity, June 1990.

5 Hebron Road, Marlborough, CT 06447 • Phone: (860) 295-9592