Adolescent Body Image Survey
Please answer the following questions about your thoughts and feelings regarding your body image. Your responses are confidential and will help us better understand adolescent experiences.
Age
*
Gender
*
Female
Male
Non-binary
Prefer not to say
Other
How satisfied are you with your overall appearance?
*
Not at all satisfied
1
2
3
4
Very satisfied
5
1 is Not at all satisfied, 5 is Very satisfied
How often do you think about your body shape or weight?
*
Never
Rarely
Sometimes
Often
Always
Please indicate how much you agree or disagree with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel confident about my body.
1
2
3
4
5
I compare my body to people I see on social media.
6
7
8
9
10
I feel pressure from friends or family to look a certain way.
11
12
13
14
15
I avoid certain activities because of how I feel about my body.
16
17
18
19
20
I believe my appearance affects my self-esteem.
21
22
23
24
25
How often do you engage in the following behaviors?
*
Rows
Never
Rarely
Sometimes
Often
Always
Exercise to change your appearance.
26
27
28
29
30
Diet or restrict food to control weight.
31
32
33
34
35
Check your appearance in mirrors or photos.
36
37
38
39
40
Talk to friends about body image concerns.
41
42
43
44
45
Who do you feel influences your body image the most?
*
Family
Friends
Social media
Celebrities/Influencers
Teachers/Coaches
Other
How do you usually feel after seeing images of models or celebrities online?
*
More positive about my body
No change in how I feel
More negative about my body
Have you ever talked to someone (parent, counselor, teacher, etc.) about your body image concerns?
*
Yes
No
Is there anything else you would like to share about your experience with body image? (Optional)
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