Physical Self-Perception Questionnaire Form
Please complete this assessment to share your views on your physical appearance, body confidence, and comfort in daily activities.
How satisfied are you with your overall physical appearance?
*
Not at all satisfied
1
2
3
4
5
6
Extremely satisfied
7
1 is Not at all satisfied, 7 is Extremely satisfied
How confident do you feel about your body in social situations?
*
Not at all confident
1
2
3
4
5
6
Extremely confident
7
1 is Not at all confident, 7 is Extremely confident
How comfortable are you with your physical abilities in daily activities (e.g., walking, climbing stairs)?
*
Not at all comfortable
1
2
3
4
5
6
Extremely comfortable
7
1 is Not at all comfortable, 7 is Extremely comfortable
How would you rate your satisfaction with your body shape?
*
Very dissatisfied
1
2
3
4
5
6
Very satisfied
7
1 is Very dissatisfied, 7 is Very satisfied
How often do you feel positive about your physical appearance?
*
Never
1
2
3
4
5
6
Always
7
1 is Never, 7 is Always
How comfortable do you feel wearing clothes that show your body shape?
*
Not at all comfortable
1
2
3
4
5
6
Extremely comfortable
7
1 is Not at all comfortable, 7 is Extremely comfortable
How much do you agree: I feel good about my physical fitness.
*
Strongly disagree
1
2
3
4
5
6
Strongly agree
7
1 is Strongly disagree, 7 is Strongly agree
How would you rate your confidence in participating in physical activities (e.g., sports, exercise)?
*
Not at all confident
1
2
3
4
5
6
Extremely confident
7
1 is Not at all confident, 7 is Extremely confident
How comfortable do you feel when looking at yourself in the mirror?
*
Not at all comfortable
1
2
3
4
5
6
Extremely comfortable
7
1 is Not at all comfortable, 7 is Extremely comfortable
Is there anything else you would like to share about your physical self-perception?
Submit Assessment
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