Lead/Tuberculosis (TB) Risk Assessment Tool

 
Patient Name: Date of Birth: Account Number:

 

LEAD ASSESSMENT:

  
1)
Has your child ever lived in or regularly visited a house or building built before 1978?
2)
Has your child lived in or visited another country? If yes, which one(s)?
3)
Has your child been exposed to or lives in a building with ongoing repair?
4) Has your child been around a family member or playmate who is being followed for lead poisoning?
5) Does your child frequently put toys, jewelry, keys or other nonfood items in his/her mouth?
6) Has your child been in contact with an adult whose job or hobby involves lead exposure? (removal of old paint; building, bridge or house remodeling; shooting range (guns/bullets); soldering pipes; recycling/fixing car radiators; melting, casting, or grinding lead, brass or bronze; making or painting ceramics; working with scrap metal; making stained glass windows)
7) Do you live near an active lead smelter, battery recycler, or an industry with lead release?
8) Do you use foreign health remedies, spices, food or leaded serving ware?
9) Do you own any pottery or ceramics made in other countries?
10) Do you have lead crystal or pewter used for cooking, storing foods, or drinking? 
11) What is the zip code of your home address?
 

TB ASSESSMENT:

 
1) Was your child born in a high-risk country? (Any country other than US, Canada, Australia, New Zealand or Western Europe) 
2) Has your child traveled to or had prolonged contact with someone from a high risk area? (India, Africa, Asia, Latin America, Eastern Europe, countries of the former Soviet Union) 
3) Has your child had close or prolonged contact with someone with infectious TB disease? 
4) Has your child had close or prolonged contact with someone with a positive TB test?
5) Has your child been in contact with someone of a high-risk group? (VA hospital, prison, nursing home)