Survey on Body Image

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Ref. No.((((Interviewer No._____

Survey on Body Image (Sample Questionnaire)

PART I
Please put a tick ( in the box that best reflects your opinion.

1. Are you aged over 25?
( Yes (Please continue answering question 2 in this part)
( No (This is the end of this survey. Thank you very much for your assistance!)

2. In general, are you satisfied with your body figure? (Interviewer please check the quota) ( Yes ( No

PART II
Please indicate how do you think about the following statements is true by circle the number. |No. |Questions |Strongly |Disagree |Neutral |Agree |Strongly | | | |Disagree | | | |Agree | | | | | | | | | |2 |I think I am shorter than I should have. |1 |2 |3 |4 |5 | | | | | | | | | |3 |I prefer to wear clothes that can hide my body shape. |1 |2 |3 |4 |5 | | | | | | | | | |4 |I need to do something to change my body figure. |1 |2 |3 |4 |5 | | | | | | | | | |5 |I am very dissatisfied with my body figure. |1 |2 |3 |4 |5 | | | | | | | | | |6 |I always take records of my body weight. |1 |2 |3 |4 |5 | |7 |I always read diet publications. |1 |2 |3 |4 |5 | | | | | | | | | |8 |I always calculate the calorie intake. |1 |2 |3 |4 |5 | | | | | | | | | |9 |I always pay attention on the issue of slimming. |1 |2 |3 |4 |5 | | | | | | | | | |10 |Celebrities’/models’ body image is my desired body image. |1 |2 |3 |4 |5 | |11 |I feel unsatisfactory to my body shape when comparing with the |1 |2 |3 |4 |5 | | |celebrities’/models’ body image. | | | | | | | | | | | | | | |12...
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