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  5. Survey About You
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Hello, You are invited to participate in our survey about you. It will take approximately 5 minutes to complete the questionnaire. Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions. Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential.
 
 
 
How old are you?
 
Less than 12
 
12-16
 
17-20
 
21-25
 
26 and over
 
 
 
How important 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
 
 
 
What do you think is the biggest cause of your body image concerns?
 
My own perception of my body
 
Peer Pressure
 
Pressure from family
 
The ideals of the media (Magazines, TV, etc)
 
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
 
N/A
 
 
 
Which Feature of your body are you most dissatisfied with? SELECT ONE
 
Arms
 
Breasts
 
Chest
 
Height- too tall
 
Height- too short
 
Hips
 
General weight- want to lose weight
 
General weight- want to gain weight
 
Legs
 
Shoulders
 
stomach/abs
 
thighs
 
 
 
Against whom do you most often compare your body?
 
Models
 
Friends
 
Actors/actresses
 
Athletes
 
 
 
Have you ever gone on a diet to change your appearance?
 
Yes, to lose weight
 
Yes, to gain weight
 
yes, to gain muscle
 
No
 
 
 
Who/what do you think the idea of "the perfect body" is more influenced by?
 
Peers of the opposite gender
 
Peers of the same gender
 
The media
 
Other