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___________________________________________________________ |
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Iowa Department of Public Health
ChildhoodLead Poisoning Risk Questionnaire
Summer 1999
[Please note:
This questionnaire has expired.]
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Yes
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No
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1. Has your child ever lived in or regularly visited a house built
before 1960? (Examples: home, day-care center, baby-sitter, relative's home)
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Yes
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No
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2. Have you noticed any peeling or chipping paint in or around the pre-1960 house
that your child has lived in or regularly visited?
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Yes
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No
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3. Is the pre-1960 home that your child has lived in or regularly visited been
remodeled or renovated by stripping, sanding, or scraping paint on the inside or
outside of the house? Removing walls and/or tearing out lath and plaster?
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Yes
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No
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4. Does your child eat non-food items such as dirt?
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Yes
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No
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5. Have any of your other children or their playmates had lead levels equal to or
greater than 15 µg/dL (micrograms per deciliter)?
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Yes
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No
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6. Does your child live with or frequently come in contact with an adult who works
with lead on the job or in a hobby? (Examples: painter, welder, foundry worker,
old home renovator, shooting range worker, battery plant worker, battery recycling
worker, ceramics worker, stained glass worker, sheet metal worker, scrap metal
worker, plumber.)
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Yes
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No
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7. Does your child live near a battery plant, battery recycling plant, or lead
smelter?
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Yes
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No
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8. Do you give your child any homemade or folk remedies? (Examples: azarcon, greta,
pay-loo-ah)
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Yes
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No
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9. Does your child eat candy that comes from Mexico or is purchased from a Mexican
grocery store? (Examples: picarindo, vero palerindas)
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Yes
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No
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10. Has your child ever lived in Mexico, Central America, South America, Africa,
Asia, or eastern Europe, or visited one of these areas for a period longer than
two months?
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