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
Copyright © 2000
Denver Pediatrics

What Our Patients Say:

This is the place to go. My daughter has a serious medical condition that has been diagnosed for the last year. We work with Children's on an regular basis but Norkio has been our life saver. Norkio advocate for my daughter with many different department at children's, oxygen companies, OT and PT's and is always happy to do so. Amy Nash is always there to fight the fight if Noriko is not. After sending us to the ER one Friday afternoon Danny called to check on us, not just on Friday but on Saturday and Sunday as well! I have never heard of a provider doing that. Countless times I have run in with my daughter having oxygen problems and been terrified, but the team at Stapleton Peds always eases my fears and takes remarkable care of my children. Rashima at the front desk is wonderful and just hearing her voice eases the panic. I just want to name everyone and mention something special about them but there are just too many special things about this practice. Katie M Nov 29,2016

Stapleton Office

2975 Roslyn Street
Suite 100
Denver, CO 80238

303-399-7900
FAX: 303-399-7999

MONDAY-FRIDAY: 8am to 5pm
SATURDAY: 8am to 12:30pm

  • Sick Visits only on Saturdays
  • Our Denver pediatrics office is closed every day from 12:30-1:30 for lunch
  • We are closed on major holidays
Mother and kids with giraffe at zoo

Pearl Street Office

1258 South Pearl Street
Suite 110
Denver, CO 80210

303-399-7970
FAX: 303-399-7905

MONDAY-FRIDAY: 8am to 5pm 
SATURDAY: Closed

  • Saturday sick appts seen at Stapleton Pediatrics office only
  • Our office is closed every day from 12:30-1:30 for lunch
  • We are closed on major holidays
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