Well Child Care Questionnaire

  1. Does your child live in or regularly visit an old house built before 1960?
    Yes ________ No ________
  2. Does the house have peeling or chipping paint?
    Yes ________ No ________
  3. Was your child's day care center/preschool/babysitter's home built before 1960?
    Yes ________ No ________
  4. Does the house have peeling or chipping paint?
    Yes ________ No ________
  5. Does your child live in a house built before 1960 with recent, ongoing, or planned renovation or remodeling?
    Yes ________ No ________
  6. Have any of your children or their playmates had lead poisoning?
    Yes ________ No ________
  7. Does your child frequently come in contact with an adult who works with lead? Examples include construction, welding, pottery, or other trades practice in your community?
    Yes ________ No ________
  8. Does your child live near a lead smelter, battery recycling plant, or other industry likely to release lead?
    Yes ________ No ________
  9. Do you give your child home or folk remedies that may contain lead?
    Yes ________ No ________
  10. Does your child live near a heavily traveled major highway where soil and dust may be contaminated with lead?
    Yes ________ No ________
  11. Does your home's plumbing have lead pipes or copper pipes with lead solder joints?
    Yes ________ No ________
  12. Does your child wear a seatbelt or sit in a restrained car seat in the car?
    Yes ________ No ________
  13. Do any of you daycare providers have tuberculosis, or an unexplained chronic cough?
    Yes ________ No ________
  14. Have you or your child traveled out of the country in the past year?
    Yes ________ No ________
    If so, where? ________________________________________________
  15. Has your child lived with or spent time with anyone who possibly or definitely had tuberculosis, or had a positive skin test for tuberculosis?
    Yes ________ No ________
  16. Did you, your child, or anyone else living in your household come to the United States from another country?
    Yes ________ No ________
    If so, from which country? ____________________________________________
  17. Has your child lived with or spent time with adults who: