Child?s name: _______________________________________________________ Date of birth: _________________

Physician Lead
Advisory Committee
Lead Risk Assessment
Questionnaire

1700 American Blvd.
Pennington, NJ 08534
Phone: 1-800-682-9091

Horizon NJ Health

High Risk Exposure Factors 6 months - 6 years
Does Your Child: (?yes? or ?I don?t know? to any question = high risk) / / / / / / / /

1. Live in or regularly visit a house with peeling or chipping paint built
before 1978? This could include the home of a baby-sitter or relative,
a daycare center or preschool.

Yes No Yes No Yes No Yes No

2. Live in or regularly visit a house built before 1978 with planned, recent
(within the past year) or ongoing renovation/remodeling activity?

3. Have a brother or sister, a playmate or other household member with a
confirmed elevated blood level?

4. Receive home or folk remedies that may contain lead?

5. Live near an active lead smelter, battery recycling plant, or other industry
likely to release lead or live with an adult whose job or hobby involes lead?

6. Have a history of possible prenatal exposure to lead
(child?s mother had elevated blood lead during pregnancy)?

7. Have iron deficiency anemia, sickle cell disease, developmental delay or
behavioral problems?

8. Have a habit of eating dirt, paint chips, or other non-food items?

9. Have excessive mouthing habits that are not age appropriate?

10. Have an elevated blood lead test 5 ug/dl or higher when last tested?

Lead prevention education and/or lead poisoning intervention material given to parent c Yes c No

Screening Schedule
Age Risk Status Blood Lead Hgb/Hct Follow Up
6 Months Low Risk No No

Date: _______________ High Risk Yes _______ ug/dl Yes ______ g/dl ______% c Yes c No
12 Months Low Risk Yes _______ ug/dl Yes ______ g/dl ______% c Yes c No
Date: _______________ High Risk Yes _______ ug/dl Yes ______ g/dl ______% c Yes c No
18 Months Low Risk No No

Date: _______________ High Risk Yes _______ ug/dl Yes ______ g/dl ______% c Yes c No
24 Months Low Risk Yes _______ ug/dl Yes ______ g/dl ______% c Yes c No
Date: _______________ High Risk Yes _______ ug/dl Yes ______ g/dl ______% c Yes c No

3 years ___________ Low Risk - Screen if previous blood lead and H&H status is not known
4 years ___________ High Risk - Re-screen yearly and add H&H
5 years ___________
6 years ___________

Products and policies provided by Horizon NJ Health and services provided by Horizon Blue Cross Blue Shield of New Jersey,
each an independent licensee of the Blue Cross and Blue Shield Association. Communications may be issued by
Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all of its companies.
? 2018 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105. CMC0011212 (0118)



Child?s name: _______________________________________________________ Date of birth: _________________

Physician Lead
Advisory Committee
Lead Risk Assessment
Questionnaire

1700 American Blvd.
Pennington, NJ 08534
Phone: 1-800-682-9091

Horizon NJ Health

High Risk Exposure Factors 6 months - 6 years
Does Your Child: (?yes? or ?I don?t know? to any question = high risk) / / / / / / / /

1. Live in or regularly visit a house with peeling or chipping paint built
before 1978? This could include the home of a baby-sitter or relative,
a daycare center or preschool.

Yes No Yes No Yes No Yes No

2. Live in or regularly visit a house built before 1978 with planned, recent
(within the past year) or ongoing renovation/remodeling activity?

3. Have a brother or sister, a playmate or other household member with a
confirmed elevated blood level?

4. Receive home or folk remedies that may contain lead?

5. Live near an active lead smelter, battery recycling plant, or other industry
likely to release lead or live with an adult whose job or hobby involes lead?

6. Have a history of possible prenatal exposure to lead
(child?s mother had elevated blood lead during pregnancy)?

7. Have iron deficiency anemia, sickle cell disease, developmental delay or
behavioral problems?

8. Have a habit of eating dirt, paint chips, or other non-food items?

9. Have excessive mouthing habits that are not age appropriate?

10. Have an elevated blood lead test 5 ug/dl or higher when last tested?

Lead prevention education and/or lead poisoning intervention material given to parent c Yes c No

Screening Schedule
Age Risk Status Blood Lead Hgb/Hct Follow Up
6 Months Low Risk No No

Date: _______________ High Risk Yes _______ ug/dl Yes ______ g/dl ______% c Yes c No
12 Months Low Risk Yes _______ ug/dl Yes ______ g/dl ______% c Yes c No
Date: _______________ High Risk Yes _______ ug/dl Yes ______ g/dl ______% c Yes c No
18 Months Low Risk No No

Date: _______________ High Risk Yes _______ ug/dl Yes ______ g/dl ______% c Yes c No
24 Months Low Risk Yes _______ ug/dl Yes ______ g/dl ______% c Yes c No
Date: _______________ High Risk Yes _______ ug/dl Yes ______ g/dl ______% c Yes c No

3 years ___________ Low Risk - Screen if previous blood lead and H&H status is not known
4 years ___________ High Risk - Re-screen yearly and add H&H
5 years ___________
6 years ___________

Products and policies provided by Horizon NJ Health and services provided by Horizon Blue Cross Blue Shield of New Jersey,
each an independent licensee of the Blue Cross and Blue Shield Association. Communications may be issued by
Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all of its companies.
? 2018 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105. CMC0011212 (0118)