SAMPLE QUESTIONNAIRE:

Thank you for participating in this survey. Please answer the questionnaire as accurately
as possible. All information will be kept strictly confidential. Thank you.

Name (Optional): _______________________________ Age: __________

Gender: M F Height: ________cm Weight: _____lbs. BMI:

1. On the figures below, please use label (A) to identify the figure that represents your
body; and use label (B) to identify your target/desired figure.

2. Please read the next set of questions below carefully and circle the number which
best describes the way that you feel about your feature/s.

Read the labels carefully to ensure you are circling the number that reflects how
you feel because some of the answers are worded in a reverse order.

2.1 Height
How satisfied are you with your current height?
0 1 2 3 4 5
|_________|_________|_________|_________|_________|
Not satisfied Slightly Satisfied Very Satisfied
2.2 Weight
How satisfied are you with your current weight?
0 1 2 3 4 5
|_________|_________|_________|_________|_________|
Not satisfied Slightly Satisfied Very Satisfied

2.3 Skin
How satisfied are you with your skin?
0 1 2 3 4 5
|_________|_________|_________|_________|_________|
Not satisfied Slightly Satisfied Very Satisfied

2.4 Facial Features

How satisfied are you with your facial features?
0 1 2 3 4 5
|_________|_________|_________|_________|_________|
Not satisfied Slightly Satisfied Very Satisfied
Reason for the rating: _________________________________
___________________________________________________
___________________________________________________

2.5 Arms
How satisfied are you with your arm size?
0 1 2 3 4 5
|_________|_________|_________|_________|_________|
Not satisfied Slightly Satisfied Very Satisfied
Reason for the rating: _________________________________
___________________________________________________
___________________________________________________

2.6 Chest
How satisfied are you with your chest size?
0 1 2 3 4 5
|_________|_________|_________|_________|_________|
Not satisfied Slightly Satisfied Very Satisfied
Reason for the rating: _________________________________
___________________________________________________
___________________________________________________
 2.7 Waist
How satisfied are you with your waist size?
0 1 2 3 4 5
|_________|_________|_________|_________|_________|
Not satisfied Slightly Satisfied Very Satisfied

2.8 Buttocks Area

How satisfied are you with your buttock size?
0 1 2 3 4 5
|_________|_________|_________|_________|_________|
Not satisfied Slightly Satisfied Very Satisfied

2.9 Thigh/Leg/Feet
How satisfied are you with your thigh/leg/foot size?
0 1 2 3 4 5
|_________|_________|_________|_________|_________|
Not satisfied Slightly Satisfied Very Satisfied

3. How often do you deliberately check your image/features?

Please include looking at yourself in a mirror or other reflective surfaces like your
cellphone or by looking at it directly or feeling it with your fingers.

0 1 2 3 4 5
|_________|_________|_________|_________|_________|
Never 1-5x a day 6-15x a day 20x or more a day

4. How often do you do the following activities because of the way you feel
about your body/features?
Please rate the degree to which you do the said activities using this scale:

0 1 2 3 4
|___________|__________|__________|___________|
Never Occasionally Often Frequently Always

a. I check my features directly by looking at it without a mirror. _______

b. I take selfies/photographs. ________
c. I compare my body/features to others in magazines/TV/internet. _______
d. I compare my body to those of my friends/people I meet. _______
e. I compare my body with old photos of myself. ________
f. I pinch the fat on my body. ________
g. I wear something to distract/cover up a feature/part of my body. _______
h. I comb or groom (smooth/straighten) or adjust my hair. ________
i. I shave, cut or pluck hair. _________
 j. I use cleansing/clearing products on my skin. _______
k. I wear make-up. _________
l. I use a concealer. ________
m. I bleach my skin. ________
n. I exercise/go to the gym. ________
o. I use weights/ body-building apparatus. ________
p. I drink/ingest supplements. ________
q. I weigh myself more than necessary. _________
r. I restrict my food to improve my shape or reduce my weight. ________
s. I eat more food to increase my weight. ________
t. I use diet pills, laxatives or diuretics. _________

Thank you for patiently answering our questionnaire.

5. What do you avoid because of the way you feel about your body/features?
Please read the situations below and in the second column rate the degree to
which you currently avoid each of these situations on the following scale:

0 1 2 3 4
|___________|__________|__________|___________|
Never Occasionally Often Frequently Always Avoid

a. I avoid going to the gym. ________

b. I avoid wearing a swimsuit on a beach/pool. ______
c. I avoid being physically close to someone. _______
d. I avoid being intimate because of my features. (or only under certain conditions
e.g. lights off or wearing your make up) _______
e. I avoid certain types of clothes. (please specify) _______
_______________________
_______________________
_______________________

f. I avoid certain types of lighting. ______

g. I avoid looking at pictures in magazines/on TV/on the internet. ________
h. I avoid having a photo or video taken by someone else. _______
i. I avoid looking at old photos of myself. _______
(Please specify if you have destroyed them) ________