Body Image & Eating Disorders

Exit Survey

Are you happy with the way you look?

If you could, what would you change about your appearance?

Have you avoided wearing clothes that make you aware of the shape of your body?

Yes

No

How concerned are you with the way others see you physically?

Very concerned

Somewhat concerned

Not concerned

How preoccupied are you with a desire to lose weight?

Very preoccupied

Somewhat preoccupied

A bit preoccupied

Not preoccupied

How often during a day do you body check? (body checking includes looking in the mirror, weighing yourself, asking others for assurance "how do I look?" "do I look fat?" etc.)

0 times a day

1-3 times a day

4-7 times a day

More than 7 times a day

How often do you compare yourself with other women? (friends, celebrities, etc.)

Never

1-2 times a day

3-5 times a day

More than 5 times a day

Does your appearance affect your level of happiness?

Yes

No

Do any of these affect the way you see and feel about yourself? Check all that apply.

Any thoughts, comments, or stories about dieting or eating disorders?