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Patient Name: ___ DOB: ___ Date: ___ Lead Risk Assessment Circle Yes or No. 1. Does your child live in or regularly visit a house/apt. That was built before 1978? Yes / No2. Does your child live in
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Mark 'Yes' if the statement is true for you, and 'No' if it is false.
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A pattern of alternating yes and no responses.
Anyone who falls under the criteria set for filing.
Simply provide the corresponding yes or no response to each question or statement.
To gather specific information in a concise manner.
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