Body Image Concerns Self-Assessment Questionnaire Form
Please complete this self-assessment to reflect on your thoughts and feelings regarding your body image. There are no right or wrong answers.
How satisfied are you with your overall body appearance?
*
Very dissatisfied
1
2
3
4
Very satisfied
5
1 is Very dissatisfied, 5 is Very satisfied
How often do you compare your body to others?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Which of the following best describes your feelings about your body image?
*
I feel positive about my body most of the time.
I have mixed feelings about my body.
I often feel dissatisfied with my body.
Other
How much time do you spend thinking about your appearance each day?
*
Less than 30 minutes
30 minutes to 1 hour
1 to 2 hours
More than 2 hours
How strongly do you agree with the following statements about your body image?
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel comfortable in my own skin.
1
2
3
4
5
I avoid certain activities because of how I feel about my body.
6
7
8
9
10
I often wish I looked different.
11
12
13
14
15
How often do you avoid social situations due to concerns about your appearance?
*
Never
1
2
3
4
Very often
5
1 is Never, 5 is Very often
Do you feel that your body image impacts your daily mood?
*
Not at all
A little
Moderately
A lot
How often do you check your appearance in mirrors or reflective surfaces?
*
Never
1
2
3
4
Very often
5
1 is Never, 5 is Very often
How would you rate the influence of social media on your body image?
*
No influence
1
2
3
4
Very strong influence
5
1 is No influence, 5 is Very strong influence
Is there anything else you would like to share about your body image concerns?
Submit
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