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NC Department of Environment and Natural Resources

Patient’s Name: _____________________________

Division of Environmental Health

Medical Record Number: _____________________

LEAD RISK ASSESSMENT

QUESTIONNAIRE

Purpose: For clinical use to identify children who need to be screened for lead poisoning. All children should

receive a blood lead test at both 12 and 24 months of age (or between 24 and 72 months of age if they have never

been tested) unless the child lives in one of the low-risk zip codes listed on the back of this page and the answers

to all five screening questions are no.

Instructions: At 12 and again at 24 months of age (or at the time of the clinic visit closest to these ages)

determine the residential zip code for all children. Also determine the zip code for children between 24 and 72

months of age who have never been tested or for whom lead screening status is unknown. Conduct a blood lead

test for children who do not live in one of the low risk zip codes listed on the back of this page. For children who

live in low risk zip codes ask the five screening questions. A yes or I don’t know answer to any question also

indicates the need for a blood lead test.

Reordering Information:

Additional copies of this form may be ordered from:

Environmental Health Services Section

Division of Environmental Health

P. O. Box 29534

Raleigh, NC 27626-0534

Date: ___________________

Age: _________________

Residential Zip Code: _______________

I don’t

Does your child:

Yes

know

1. Receive Women, Infants, and Children (WIC) Program Services

or is your child enrolled in Medicaid (Health Check) or Health Choice? ......................

2. Live in or regularly visit a house that was built before 1950, including

home child care centers or homes of relatives? ...............................................................

3. Live in or regularly visit a house that was built before 1978, with

recent or ongoing renovations or remodeling (within the last 6 months)? ......................

4. Live in or regularly visit a house that contains vinyl miniblinds? ...................................

5. Have a brother, sister, other relative, housemate or playmate who

has or has had a high blood lead level? ............................................................................