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Are you male or female?
 
Male
 
Female
 
 
 
How important to you is your appearance?
 
Very important
 
Moderately important
 
Slightly important
 
Not important
 
 
 
What do you think is the biggest cause of your body image concerns?
 
My own perception of my body
 
Peer pressure
 
Pressure from family
 
The ideals of the media (magazines, tv, etc.)
 
Other
 
 
 
Against whom do you most often compare your body?
 
Actors/actresses
 
Athletes
 
Friends
 
Models
 
Other (please specify)
 
 
 
Have you ever gone on a diet to change the way you look?
 
Yes, to lose weight
 
Yes, to gain muscle
 
No
 
Other (please specify)
 
 
 
Who/what do you think the idea of "the perfect body" is more influenced by?
 
Peers of the opposite gender
 
Peers of the same gender
 
The media (magazines, tv, etc)
 
Other (please specify)
 
 
 
Do you think young adults and teens are more likely to be influenced by media than other age groups?
 
Yes
 
No
 
 
 
Do you think media exposure affects us negatively?
 
Yes
 
No
 
 
 
Who will have the most impact from the media?
 
Children
 
Teens
 
Adults
 
Other
 
 
 
 
Do you think media affects how we see ourselves?
 
Yes
 
No
 
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