Media History

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