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Gender?
 
Male
 
Female
 
Other
 
 
 
How important to you is your appearance?
 
Very important
 
Moderately important
 
Slightly important
 
Not important
 
 
 
Would you say the pressures of body image (looking a certain way) affect you?
 
Yes
 
No (Skip to question 7)
 
 
 
What do you think is the biggest cause of your body image concerns?
 
My own perception of my body
 
Peer pressure
 
Family pressure
 
The media
 
Other
 
 
 
Which of these do you relate to most as an effect of body image?
 
Being insecure around people
 
Embarrassment
 
Gaining motivation to exercise, eat healthier, etc.
 
General unhappiness
 
Lowered self worth
 
Undesirable to the opposite sex
 
Other
 
 
 
Do you often compare you body to those of others?
 
Yes
 
No
 
 
 
Against whom do you most often compare your body
 
Actors/ actresses
 
Athletes
 
Friends
 
Models
 
I do not compare my body with others
 
Other
 
 
 
 
Have you ever gone on a diet to change the way you look?
 
Yes- to lose weight
 
Yes- to gain weight
 
Yes- to gain muscle
 
No
 
Other
 
 
 
Who/ what do you think the idea of "the perfect body" is more influenced by?
 
Peers of opposite gender'
 
Peers of same gender
 
The media
 
Other
 
 
 
Has
anyone ever made a comment about your body that you were uncomfortable with?
 
Yes
 
No
 
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