Lead Poisoning Screening Form

1.  About your home:

    a.  Year home built?    

Unknown Before 1950 1950-1978 After 1978 - Go to question #2

    b.  Peeling or flaking paint inside home?                                         

Yes No

    c.  Porches used as play areas?                                                      

  Yes No

    d.  Peeling or flaking paint on the outside?                                   

Yes No

    e.  Paint removal, renovation, or remodeling in the last six months?  

Yes No

2. Does your child regularly spend time at another home (babysitter, grandparent, etc.) that was built before 1978?                                                            

Yes No              

3.  Can your child put mouth on windowsills or reach into window wells (space between inner and outer windowsills) at home?                                                      

Yes No

4.  Do your child's main outdoor play areas include areas of bare soil near painted buildings or porches, or near roads with heavy traffic?                    

Yes No                         

5.  In the last six months, have any buildings near your home had exterior painting or renovations?                                                                                 

Yes No

6.  Is anyone in your home exposed to lead at work (such as smelter, brass foundry, radiator repair, motor vehicle batteries, paints or pigments, ammunition/firing range, demolition, home/building remodeling or repair, paint removal, soldering, glass products, or other lead-related trades)?  Anyone with hobbies involving ceramic glazes, oil paints, furniture refinishing, fishing weights, ammunition, metal toy soldiers, stained glass, or other lead sources?                                                                                           

Yes No

7.  Does your family use tap water for drinking or cooking?                        

Yes No        

8.  Does your family use pottery, pewter, or crystal for cooking or eating?   

Yes No    

9.  Does your child mouth/chew on almost anything?                                    

Yes No  

10. Does your family eat imported canned foods (like tomatoes, fruit)?         

Yes No    

11.  Are imported vinyl mini-blinds in your home?                                        

Yes No

12.  Is your child underweight or anemic (iron-poor blood), or is your child's diet low in calcium (milk or dairy products) or iron (iron-fortified formula/cereals or red meat)?                                                                                                      

Yes No    

13.  Does anyone in your home use home remedies like greta, azarcon, pay-loo-ah, or others?  Health store products like dolomite?  Traditional cosmetics like surma or kohl?                                                                                                        

Yes No

    If yes, specify_______________________________________________________

14.  Is painted wood burned in or near your home?                                       

Yes No

15.  Does your family live near an industry that uses lead?  (See Question 6)

Yes No   

16.  Has your child lived or traveled outside the US?                                   

Yes No        

For more information about lead poisoning visit the following websites:

     RI Department of Health

    Alliance for Healthy Homes

     Coalition to End Childhood Lead Poisoning

     EPA Lead Awareness Program

     Center for Disease Control and Prevention-Childhood Lead Poisoning

   Department of Housing and Urban Development Office of Healthy Homes and Lead Hazard Control

or Call:

The National Lead Information Center (800) 424-LEAD

Environmental Protection Agency (EPA) Safe Drinking Water Hotline (800) 426-4791

Reproduced with permission of the authors Seth Foldy, M.D. and Helen Binns, M.D.
Copyright © 1999 Seth Foldy and Children's Memorial Hospital. All rights reserved.
Revised: 10/01/07

Disclaimer: This website is intended to provide information. It is not intended to, nor does it constitute medical or other advice. Readers are warned not to take any action with regard to medical treatment or otherwise based on the information on this website without first consulting a physician.