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Media History

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Please check one answer for each question. If the question does not apply to your family (ie, you do not own a computer or mobile device), leave that section blank.

Child's Name __________

Date __________

Television (including on mobile screens)
Does your child watch more than 1 to 2 hours of TV per day? □ Frequently □ Sometimes □ Never
Do you watch TV with your child or know what your child is watching? □ Frequently □ Sometimes □ Never
Do you discuss TV shows with your child? □ Frequently □ Sometimes □ Never
Does your child have a TV in his or her room? □ Yes □ No
Do you limit your child's watching of TV shows that often contain violence, sex, foul or explicit language, or images of tobacco or alcohol use? □ Frequently □ Sometimes □ Never
Do you have rules about when TV can be watched? □ Yes □ No
Do you allow your child to eat meals or snacks while watching TV? □ Yes □ No
Does your child ask you to buy products he or she sees advertised on TV? □ Frequently □ Sometimes □ Never
Movies and Videos
Do you allow your child to watch movies or videos that are R-rated? □ Frequently □ Sometimes □ Never
Do you read movie reviews to know the content of PG-13 movies? □ Frequently □ Sometimes □ Never
Does your child have nightmares or trouble sleeping after watching movies? □ Frequently □ Sometimes □ Never
How often does your child watch music videos on TV? □ Frequently □ Sometimes □ Never
Music
Are you familiar with the type of music your child listens to? □ Yes □ No
Have you talked to your child about lyrics that you object to? □ Yes □ No
Do you set limits on the types of music your child listens to? □ Yes □ No
Video Games (including handheld)
Are you familiar with the types of games your child plays? □ Yes □ No
Do you check a game's rating before you rent or buy it? □ Yes □ No
Do you allow your child to own or download games with violent content? □ Frequently □ Sometimes □ Never
Do you limit the number of hours your child plays these games? □ Frequently □ Sometimes □ Never
Internet (Web sites, including social networking sites accessible by computer and handheld devices)
Do you monitor Internet use? □ Frequently □ Sometimes □ Never
Does your child have a computer in his or her room? □ Yes □ No
Are you familiar with the types of Web sites your child visits? □ Yes □ No
Do you talk to your child about the best use of the Internet? □ Frequently □ Sometimes □ Never
Have you purchased blocking software that prevents your child from visiting inappropriate/pornographic Web sites? □ Yes □ No
Books
Do you read to your child or does your child read at least once a day? □ Yes □ No
Do you provide your child with a variety of reading materials? □ Yes □ No
Do you talk to your child about the books that you read together or that your child is reading on his or her own? □ Frequently □ Sometimes □ Never
Do you have any specific concerns about:
Your child's use of tobacco, alcohol, or illicit drugs? □ Yes □ No
Your child's own sense of body image or sexuality? □ Yes □ No
Displays of aggressive behavior or use of foul language? □ Yes □ No
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Additional Resources

HealthyChildren.org is the only parenting website backed by 66​,000 pediatricians committed to the attainment of optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults
KidsHealth is the most-visited site on the Web for information about health, behavior, and development from before birth through the teen years.

The Center on Media and Child Health (CMCH) at Boston Children’s Hospital (BCH) is an academic research center whose mission is to educate and empower children and those who care for them to create and consume media in ways that optimize children’s health and development.
Common Sense is the leading independent nonprofit organization dedicated to helping kids thrive in a world of media and technology
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    Dr. P joined the practice in July, 1972 along with Drs. Kuperstein, Zonis, and Russell Irons. He has worked tirelessly for our practice and patient families for the past 46 years, and we wish him luck as he and Wendy enjoy their children and grandchildren as well as the beaches of Maine and the Cape!

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