Lead Risk Assessment Questionnaire

Illinois Department of Public Health

ALL CHILDREN 6 MONTHS THROUGH 6 YEARS OF AGE MUST BE ASSESSED FOR LEAD POISONING
(410 ILCS 45/6.2)
The screens you are filling out will be billed to your insurance. We recommend these screens as they follow the best practice as set forth by the American Academy of Pediatrics
You have the right to decline these screens.

If you decline to fill out this form, please select 'Decline' and continue with the required information.

You have the right to decline these screens.

If you decline to fill out this form, please select 'Decline' and continue with the required information. Decline
Name Name * First Last
Age
DOB DOB * / MM / DD YYYY
Zipcode