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Are you male or female? 
 
Male
 
Female
 
 
 
What grade are you in?
 
9
 
10
 
11
 
12
 
 
 
I am satisfied with my appearance.
 
Strongly Agree
 
Agree
 
Disagree
 
Strongly Disagree
 
 
 
Do you feel limited to certain articles of clothing when shopping?
 
Always
 
Often
 
Sometimes
 
Never
 
 
 
Do you believe media is the greatest impact on the way you view yourself?
 
Always
 
Often
 
Sometimes
 
Never
 
 
 
How often do you compare your body physique to others around you?
 
Always
 
Often
 
Sometimes
 
Never
 
 
 
Is your negative body image a result of what others say about you or what you say about yourself?
 
Strongly Agree
 
Agree
 
Disagree
 
Strongly Disagree
 
 
 
Does your concern over body image effect the way you eat?
 
Always
 
Often
 
Sometimes
 
Never
 
 
 
How often do you conduct surveys?
 
Weekly
 
Monthly
 
Quarterly
 
Annually
 
 
 
Do you limit the places you go, due to lack of self confidence?
 
Always
 
Often
 
Sometimes
 
Never
 
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