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The Lead Education and Abatement Design Group
Working to eliminate lead poisoning globally and to protect the
environment from lead in all its uses: past, current and new uses
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PDF of this file

Medical Evaluation Questionnaire for Occupational Lead Exposure

By the Massachusetts Division of Occupational Safety
modified by Elizabeth O'Brien, The LEAD Group Inc, November 2010


Nationality: ________________________________

Country of Birth: _______________________________

Medicare / Medicaid / Social Security #____________________________

Date of birth:_______________________________

Male __________ Female _________

Employer: __________________________________________________

Employer's address:___________________________________________


Contact person: ____________________________

Phone: _________________________

Address to send results to: _____________________________________


Phone: _________________________

Other employer(s) in past year: __________________________________


Exposure History

Past lead-related employers and hobbies (dates / years worked, country):




Description of current job: __________________________________________


Job tasks in past year (check all that apply)

_____Ironwork: cutting/burning/welding painted surfaces
         or lead-containing scrap metal

_____Painting / brushing with lead paint____ Spray painting with lead paint

_____paint applications: applying lead paint as a powder

_____Lead paint containment: erecting/removing barriers or covers

_____paint removal: __dry scraping __chemical removal __power sanding

_____burning _____ abrasive blasting

_____cleanup: ___sweeping ___standard vacuum ___HEPA vacuum

_____Battery manufacturing / recycling

_____Lead soldering ____Lead smelting _____ Foundry work

_____Radiator repair _____Metal machining or grinding

_____Wire or cable manufacture _____Plastics / PVC manufacture

_____Scrap metal recycling_________Ammunition manufacture

_____Demolition______Other lead work (specify)_______________________

Other possible current or recent exposures:

____Leadlighting / Stained glass ____ Pottery /ceramics ____ Folk medicines:

_____Ayurvedic medicine_____Chinese herbal medicine________Other


____Firing range use or maintenance ____Making bullets or shot

______Making fishing sinkers_______Home or other building renovation

______Furniture or mirror renovation_______Burning painted wood

_________Home car maintenance______Home auto paint renovation

_______Regular use of hair colour restorer or other leaded cosmetics

_________Regular use of pewter for_______food or ________drink. Specify

the food or drink and the frequency:___________________________________

_________Regular use of crystal for________food or _______drink. Specify

 the food or drink and the frequency:__________________________________

________Regular ingestion of turmeric. Specify frequency: _______________

_______Regular ingestion of imported canned foods (specify)______________

______Regular ingestion of Chinese preserved eggs. Specify frequency: _____

Comments (eg favourite foods if unusual): _____________________________


Protective measures

Respirator: (check those used) _____Dust mask (disposable)

_____Standard canister (negative-pressure) respirator

_____Negative-pressure respirator, with HEPA filter

_____Powered air-purifying respirator

_____Supplied-air respirator

Have you been fitted for respirator and trained in its uses?



Have you had any difficulty wearing a respirator?



Do you: eat or drink in the work area?



smoke in the work area?



wash your hands before eating or smoking?



wear your work clothes home?



Are facilities available for: eating in clean area?









laundering of work clothes by the workplace?



Do you know of others you work with who have had high lead levels?



Do your co-workers have low blood lead levels?



Have you had previous lead tests?

Dates and results, if known:_________________________



Have you needed treatment for lead poisoning before, or

removal from lead exposure because of a high level?



Current Symptoms Y N Comments

Weight loss ____________________________________________

Fatigue _______________________________________________

Poor sleep _____________________________________________

Metallic taste in mouth_____________________________________

Loss of appetite _________________________________________

Abdominal pain _________________________________________

Nausea/vomiting _________________________________________

Pain in teeth ____________________________________________

Constipation ___________________________________________

Irritability ______________________________________________

Headaches _____________________________________________

Memory problems _______________________________________

Difficulty concentrating ___________________________________

Hearing loss ____________________________________________

Numbness or tingling of
hands or feet ___________________________________________

Joint pain ______________________________________________

Change in sex drive ______________________________________

(Women) Change in
menstrual periods ________________________________________

Other _________________________________________________

Past Medical History

Y N Comments

Have you ever had:

High blood pressure ______________________________________________

Kidney disease __________________________________________________

Anemia/low blood count ____________________________________________

Heart disease ___________________________________________________

Asthma ________________________________________________________

Emphysema ____________________________________________________

Bronchitis ______________________________________________________

Gout __________________________________________________________

Arthritis ________________________________________________________

Head injury _____________________________________________________

Depression _____________________________________________________

Difficulty conceiving a child ________________________________________

A child with a birth defect
or learning disability ______________________________________________

(Women) Miscarriage ______________________________________________

Social and Family History

Do any children live in your home? _____Yes _____No. If Yes,

 Ages, Male / Female:_____________________________________________

When was your home built (if known)? __________

Is there any lead paint in it? ____Yes ____ No ____ Don't know

Do you smoke cigarettes? ____Yes ____No If Yes, packs per day

____________Brand:____________, or Bagged loose tobacco:__________

Has alcohol ever been a problem for you? _____Yes _____No

When was your last drink? __________

Physical Examination

Height_____ Weight _____ BP_____ P_____

Normal Abnormal Comment

HEENT (lead line optic disc) ________________________________________

Heart ___________________________________________________________

Lungs __________________________________________________________

Abdomen _______________________________________________________

Cranial nerves ___________________________________________________

Motor strength (esp wrist extensors)__________________________________

Sensory (esp distal) _______________________________________________

Coordination ____________________________________________________

Affect __________________________________________________________

Orientation (place, person, time) _____________________________________

Memory (object recall) _____________________________________________

Attention (serial 7s) _______________________________________________

Visual-spatial (design copying) ______________________________________

Laboratory tests ordered:

Whole blood lead _____ ZPP _____

Hgb _____ Hct _____ MCV _____ Smear __________________

BUN _____ Creat _____ U/A ____________________________

Iron studies_____________________________________________

Other __________________________________________________

Optional tests: Sperm analysis __________

Pregnancy test __________

Nerve conduction velocity __________

Medical Evaluation for Lead Exposure

Results and Recommendations

(copy to employer and employee)

Name:__________________________________ Date of birth: ____________

Date of evaluation:_______________

Blood lead level:_______

Any condition detected which increases risk from exposure to lead? ____Yes

____No. Specify:_________________________________________________

Duty status:

_____Continued duty

_____Continued duty, but review of protective measures

_____Medical removal from lead exposure, with wage protection*

_____Medical removal and chelation therapy**

Respirator use:

_____No restrictions on use

_____Use with following accommodations: ____________________________

_____Not approved for respirator use

Follow-up:_____Follow-up medical evaluation in _____ days / weeks***

_____Follow-up blood lead test in _____ days / weeks / months****

_____Lead test dust wipes____at workplace____at home____at hobby location

_____Blood lead test co-workers ______co-habitants______child co-habitants

Nutritional intervention: ____________________________________________

PDF of this file

The LEAD Group Inc. Fact Sheet Index

NSW Lead Reference Centre and NSW Government Publications On this site

  1. About the Global Lead Advice and Support Service (GLASS)

  2. Main Sources of Lead

  3. How Would You Know If You or Your Child Was lead poisoned?

  4. Lead aware housekeeping

  5. Ceiling dust & lead poisoning

  6. Is your yard lead safe?

  7. Health Impacts of lead poisoning

  8. Rotary Questionnaire

  9. Lead poisoned Pets and Your Family

  10. Childhood Lead Poisoning Risk Factor Questionnaire

  11. Is Your Child Safe From Lead? - What Can You Do About Lead?

  12. Lead in Drinking Water in Australia

  13. Have We Really Resolved The Lead Issue?

  14. The Importance of the Availability of "Spot Tests" for Lead in Paint

  15. Pregnant or Planning a Pregnancy

  16. Breastfeeding and Lead

  17. Lead in breast milk

  18. Beware The Lead In Lead Lighting

  19. Renting and Lead

  20. What to do if you have too much lead in your tank water

  21. Lead Contamination in Stormwater

  22. Contamination At Shooting Ranges

  23. Banned: Leaded Wick Candles

  24. Lead, Ageing and Death

  25. Metal miniatures: How to minimise the risks of lead poisoning and contamination

  26. 7 Point Plan for the MANAGEMENT OF LEAD by Australian parents and carers

  27. Countries where Leaded Petrol is Possibly Still Sold for Road Use, As at 17th June 2011

  28. Lead Poisoning And The Brain - Cognitive Deficits And Mental Illness

  29. Facts and Firsts of Lead

  30. Lead mining royalties by state and territory

  31. Lead Mining Stewardship - Grey Lead and the Role of The LEAD Group

  32. Preventative Strategies of The LEAD Group

  33. What do Doctors need to do about Lead?

  34. A Naturopath's Experience Of Lead & People With Diagnosed Mental Illness

  35. Case File: Helping Manage Australian Lead in Petrol - How GLASS Works

  36. Glass Web & Service-Users, Experts & Volunteers, by Country; Countries with Leaded Petrol for Road Use & Worst Pollution

  37. Lead in ceiling dust

  38. Lead paint & ceiling dust management - how to do it lead-safely

  39. Esperance parliamentary inquiry follow-up factsheet: Where to from Here??

  40. Broken Hill lead miners factsheet 1893 with Note 20081015

  41. Helping a Doctor Help 35,000 Lead-Poisoned People Around the Lead Smelter at La Oroya in Peru
    Ayuda a un doctor que ayuda 35,000 personas envenenadas por plomo alrededor de la fundidora de plomo en la Oroya-Peru

  42. Fact sheet for Australian toy importers and traders

  43. Iron Nutrition & Lead Toxicity
    Informe de Acciones – Hierro y Plomo en la Nutrición

  44. Sanitarium-Are You getting Enough Iron

  45. Do-It-Yourself-Lead-Safe-Test-Kits-flyer

  46. Blood lead testing: who to test, when, and how to respond to the result

  47. Dangers of a blood lead level above 2 µg/dL and below 10 µg/dL to both adults and children

  48. Lead Exposure & Alzheimer’s Disease: Is There A Link?

  49. In CHINA - Blood lead testing: who to test, when, and how to respond to the result

  50. Why you should have your ceiling dust removed before you take advantage of the Australian government's Energy Efficient Homes Package: Insulation Program

  51. Alperstein et al Lead Alert - A Guide For Health Professionals 1994

  52. Ceiling Dust WorkCover Guide Lee Schreiber Final Nov 1999

  53. What can I do about climate change AND lead?

  54. The Need for Expert Clinical Assessments in Diagnosis Of Heavy Metal Poisoning

  55. Why you should have your ceiling dust removed before you have insulation installed

  56. Thirty Thought-Starters on Ceiling Void Dust in Homes

  57. Pectin: Panacea for both lead poisoning and lead contamination

  58. Nutrients that reduce lead poisoning June 2010

  59. Lead poisoning and menopause

  60. Fact sheet For Schoolkids From Professor Knowlead About Lead

  61. Prevention of Exposure to Lead at Work in Indonesia

  62. Mencegah kontak dengan timbal di tempat kerja di Indonesia

  63. How to Protect Your Family from Lead in Indonesia

  64. Bagaimana melindungi keluargamu dari timbal di Indonesia

  65. Cigarette Smoking & Lead Toxicity
     صحيفة معلومات: التدخين والتسمم بالرصاص

  66. Medical Evaluation Questionnaire For Occupational Lead Exposure

  67. Dangers of a blood lead level above 2 µg/dL and below 10 µg/dL to children

  68. Dangers of a blood lead level above 2 µg/dL and below 10 µg/dL to adults

  69. Biosolids used as fertilizer in China and other countries

  70. What are the lead poisoning risks of a lead pellet, bullet or shot lodged in the body?

  71. Alcohol’s link to higher lead and iron levels

  72. USA Case Definition of Adult (including Occupational) & Child Elevated Blood Lead Levels (EBLL)

  73. Low Level Lead Exposure Harms Children - A Renewed Call for Primary Prevention

  74. Occupational Health & Safety Fact Sheet Dangers of lead for roofers

  75. Let’s Make Leaded Petrol History - Let’s Make Leaded Gasoline History

  76. Lead, Your Health & the Environment. Available in Arabic, Chinese, English, Korean, Macedonian, Spanish, Turkish and Vietnamese 

  77. Lead Safe Housekeeping

  78. Old Lead Paint

  79. Working safely with lead

  80. A Renovator's Guide To The Dangers Of Lead (Brochure 30 pages)

  81. A Guide For Health Care Professionals (Brochure 34 pages)

  82. A Guide To Keeping Your Family Safe From Lead (Brochure 20 pages)

  83. Lead Hazard Management In Children's Services (Brochure 15 pages)

  84. A Guide To Dealing With Soil That Might Be Lead-Contaminated

  85. Exposure Assessment: Lead Neurotoxicity - Is the Center for Disease Control's goal to reduce lead below 10 µg/dl blood in all children younger than 72 months by 2010, good enough?

About Us | bell system lead poisoning | Contact Us | Council LEAD Project | egroups | Library - Fact Sheets | Home Page | Media Releases
| Q & A | Referral lists | Reports | Site Map | Slide Shows - Films | Subscription | Useful Links |  Search this Site

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 Last Updated 01 May 2014
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PO Box 161 Summer Hill NSW 2130 Australia
Phone: +61 2 9716 0014