Pediatrics Symptoms checklist ( Doctor Questions to Parents)

                                                    "Doctor Questions to parent's"

Circle the letters for the correct answer of the meaning of the words or sentence.

1.) Has your child been exposed to anyone with tuberculosis?

    a.) Yes

    b.) no

    c.) not sure

2.) was your child born in, or has he/she live in a foreign country?

    a.) yes

    b.) no 

    c.) not sure

3.) Is your child exposed to anyone who is a resident of a correctional facility?

    a.) yes

    b.) no

    c.) not sure

4.) Do you have well water?

    a.) yes

    b.) no

    c.) not sure

5.) Does your child now live, or has he/she ever lived in a house or apartment built before 1978?

    a.) yes

    b.) no

    c.) not sure

6.) Is any adult in your family exposed to lead in other occupation or hobby?

    a.) yes

    b.) no

    c.) not sure

7.) Has anyone in your child's home been diagnosed with lead poisoning?

    a.) yes

    b.) no

    c.) not sure

8.) Do you have any reason to think your child may have been exposed to lead?

    a.) yes

    b.) no

    c.) not sure

9.) Is your child exposed to anyone who is HIV positive?

    a.) yes

    b.) no

    c.) not sure

10.) Is your child exposed to anyone who regularly smokes cigarettes?

    a.) yes

    b.) no

    c.) not sure

11.) Is your child exposed to anyone who has Low immunity or is undergoing chemotherapy?

    a.) yes

    b.) no

    c.) not sure

12.) Is your child exposed to anyone who has substance abuse problems?

    a.) yes

    b.) no

    c.) not sure.