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By Neil A. Rector

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Additional resources for Obsessive-compulsive Disorder: An Information Guide, a Guide for People With Obsessive-compulsive Disorder And Their Families

Example text

RENT IF RENTED, ARE THERE ANY RENT SUBSIDIES? OWN YES (CIRCLE) NO (CIRCLE) IF YES, WHAT TYPE: (CHECK) PUBLIC HOUSING AUTHORITY _ _ SECTION 8 _ _ FEDERAL RENT SUBSIDY _ _ OTHER (SPECIFY): _ _ _ _ __ LANDLORD INFORMATION (OR RENT COLLECTOR AGENT) NAME: ______________________________________________________ ADDRESS: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ PHONE: _____________________________________________________ 3. WHEN DID YOU/YOUR FAMILY MOVE INTO THIS HOME? COMPLETE THE FOLLOWING FOR ALL ADDRESSES WHERE THE CHILD HAS LIVED DURING THE PAST 12 MONTHS: GENERAL CONDITION OF DWELLING: DATES OF ADDRESS (INCLUDE ApPROXIMATE ANY REMODELING OR RENOVATION?

3. 4. OTHER SAMPLING (SPECIFY): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ WATER LEAD HAZARDS 1. WHAT IS THE SOURCE OF DRINKING WATER FOR THE FAMILY? ) IF TAP WATER IS USED FOR DRINKING, PLEASE ANSWER THE FOLLOWING: 2. FROM WHICH FAUCETS DO YOU OBTAIN DRINKING WATER? ) 3. Do YOU USE THE WATER IMMEDIATELY OR DO YOU LET THE WATER RUN FOR AWHILE FIRST? (IF WATER LEAD LEVELS ARE ELEVATED IN THE FIRST FLUSH, BUT LOW IN THE FLUSHED SAMPLE, RECOMMEND FLUSHING THE WATER AFTER EACH PERIOD THE WATER 6 HAS REMAINED STANDING IN THE PIPE FOR MORE THAN 4.

DOES ANYONE IN THE HOUSEHOLD MELT LEADS TO MAKE BULLETS OR FISHING SINKERS? 10. DOES ANYONE IN THE HOUSEHOLD WORK IN AUTO BODY REPAIR AT HOME OR IN THE 11. Is YARD? THERE EVIDENCE OF TAKE-HOME WORK EXPOSURES OR HOBBY EXPOSURES IN THE DWELLING? ASSESSMENT: (CHECK) PROBABLE OCCUPATIONAL-RELATED LEAD EXPOSURE. _ _ _ PROBABLE HOBBY-RELATED LEAD EXPOSURE. 49 50 GETTING THE LEAD OUT ACTIONS: (CHECK) COUNSEL FAMILY (SPECIFY): _ _ REFER TO (SPECIFY): _ _ _ _ _ _ _ _ __ CHILD BEHAVIOR RISK FACTORS 1. 2.

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