American Lead Poisoning Help Association, Inc.

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Risk Assessment Questionnaire

Are you or your family members at risk for being exposed to lead?  Complete this Risk Assessment Questionnaire and bring it to your family doctor or pediatrician.  For a list of possible sources of Lead please see our Lead 101 page.



Was your home built before 1978?
¿Se construyó su casa problemente antes de 1978?


How long have you lived at this address?
¿Cuánto tiempo ha vivido en esta dirección?


What was your previous address?
¿Cuál era su dirección anterior?

4.Was your previous home built before 1978?
¿Se construyó su dirección anterior problemente antes de 1978?

Is there any peeling paint on the outside or inside of your home?
¿Hay pintura desprendida en tiras dentro o fuera de su hogar?


Has any recent remodeling of your home involved paint removal or the use of old or recycled lumber?
¿Ha hadibo renovaciones recientes de su hogar que hayan involucrado el removimiento de pintura o el uso de maderas viejas o recicladas?


Does your child spend time at any other building (daycare center, Grandparent's house, neighbor's house, etc.) that was probably built before 1978 or that has had recent renovations?
¿Pasa su niño o niña tiempo en algún otro edificio (centro de guardería, de los abuelos, casa de vecinos, etc.) que probablemente halla sido construido antes de 1978 o que haya tenido renovaciones recientes?


Does anyone in your family use alternative, traditional, or home remedies such as Greta, Azarcon, Maria Luisa, or Pay-loo-ah?
¿Hay alguno de su familia que use remedies alternatives, tradicionales, ocaseros, como Greta, Azarcon, Maria Luisa, o Pay-loo-ah?


Does your child put non-food items, like paint or dirt, in his or her mouth?
¿Se lleva a la boca, su niño o niña, cosas no comestibles ( como pintura o tierra)?


If your house is heated by a wood-burning stove or fireplace, is painted wood burned as fuel?
Si calienta usted su casa con estufa de leña o chimenea ¿Quema usted Madera recubierta de pintura como combustible?


Does anyone in your home make bullets, make fishing weights, make stained glass, make or glaze pottery, or work on autos near the house?
¿Alguien en su hogar manufactura balas, pesas para cañas de pescar, vidrio de colores; ques manufacture o aplique vidriado a la cerámica o que arregle autos cerca de la casa?


Where are members of your household employed?
¿En dónde trabajan los miembros de su familia?

13.What is their main job?
¿Principalmente en qué trabajan?

Are acid containing foods like fruit juice stored in pottery, porcelain, pewter, leaded crystal, or cans?
¿Almacena usted comida de alto contenido de acido, como jugos de fruta, en recipients de barro, porcelana, peltre, crystal de plomo, o en latas?


Do you cook, serve, or store food in a bean pot or in pottery that is glazed?
¿Cocina o guarda usted comida en olla para frijoles, en alfarería recubierta con vidriado que contenga plomo?


Are there factories near the place where your child spends most of his time?
¿Se encuentran fábricas cerca del lugar en donde su niño o niña pas alas mayor parte del tiempo?


Have other members of the family or any of your child's friends had high blood lead levels?  If yes, who?
¿Hn tenido otros miembros de la familia o cualqueiera de los amigos de sus niños altos niveles de plomo en la sangre?  Si su respuesta fué sí, quienes?


If you have answered Yes to any of these questions please take this form to your doctor or pediatrician.

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