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What is your age (women)?
 
13-19
 
20-30
 
31-40
 
+40
 
 
 
 
How important to you is your appearance?
 
Very important
 
Moderately important
 
Slightly important
 
Not important
 
 
 
What do you think is the biggest cause of your body image concerns?
 
Pressure from family
 
Peer pressure from friends
 
Media (e.g magazines, social media)
 
My own perspective of my body
 
Other
 
 
 
 
What best describes your shape?
 
Thin and probably not healthy
 
Average but healthy
 
Overweight and probably not healthy
 
Big and beautiful
 
Thin but healthy
 
Curvy and gorgeous
 
Athletic and healthy
 
Other
 
 
 
 
Do you compare yourself to female images in media?
 
Yes
 
sometimes
 
No
 
 
 
Are you overly critical of yourself
 
Yes
 
No
 
 
 
What types of credit cards do you have (Select all that apply)?
 
Skipped meals
 
Changed your eating habits
 
Made yourself throw up
 
Taken pills or other drugs
 
Exercised excessively
 
Other
 

 
 
 
Against whom do you most often compare your body?
 
Actors/actresses
 
Athletes
 
Friends
 
Models
 
Other
 
 
 
 
What’s your favorite body part?
 
My stomach
 
My hips
 
My thighs
 
My butt
 
My legs
 
My arms
 
My breasts
 
My back
 
none of them
 
All of it
 
 
 
And your least favorite body part?
 
My stomach
 
My hips
 
My thighs
 
My butt
 
My legs
 
My arms
 
My breasts
 
My back
 
none of them
 
All of it
 
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