Survey on Body Image

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 |I am very envious of those celebrities’/models’ body figures appear on those |1 |2 |3 |4 |5 | | |slimming advertisements. | | | | | | | | | | | | | |13 |I want to look as good as a model/celebrity. |1 |2 |3 |4 |5 | | | | | | | | |14 |I think celebrities’/models’ body image is a symbol of beauty. |1 |2 |3 |4 |5 | | | | | | | | | |No. Questions |Strongly |Disagree |Neutral |Agree |Strongly | | | |Disagree | | | |Agree | | | | | | | | | |16 |I believe I would have more job opportunities if I have a good figure. 1 |2 |3 |4 |5 | |17 |I believe I would have longer life if I have a good figure. |1 |2 |3 |4 |5 | |18 |I believe I would have many admirers if I have a good figure. 1 |2 |3 |4 |5 | | | | | | | | | |19 |I believe I would have more acceptances in social life if I have a good |1 |2 |3 |4 |5 | | |figure. | | | | | | |20 |People around me are more likely to make friends with slim people. 1 |2 |3 |4 |5 | |21 |People around me would use different ways to keep body shape. |1 |2 |3 |4 |5 | | | | | | | | | |22 |People around me do not satisfied with their body figure. 1 |2 |3 |4 |5 | | | | | | | | | |23 |People around me like discussing on their body shape. 1 |2 |3 |4 |5 | | | | | | | | | |24 |I feel not in the group if I am fatter than people around me. |1 |2 |3 |4 |5 | | | | | | | | | |25 |I do mind if people play a joke on my body figure. 1 |2 |3 |4 |5 | | | | | | | | | |26 |IÂ  do mind if I find that I have gained some weight. |1 |2 |3 |4 |5 | | | | | | | | | |27 |I do mind people telling me I am fat. 1 |2 |3 |4 |5 | | | | | | | | | |28 |I feel bad talking to another female with slim body. |1 |2 |3 |4 |5 | | | | | | | | | |29 |I feel guilty when I eat too much. 1 |2 |3 |4 |5 | | | | | | | | | |30 |All in all, I am inclined to feel that I am a failure |1 |2 |3 |4 |5 | | | | | | | | | |31 |I take a positive attitude toward myself |1 |2 |3 |4 |5 | | | | | | | | | |32 |I have confidence in myself. 1 |2 |3 |4 |5 | | | | | | | | | |33 |At times I think I am no good at all |1 |2 |3 |4 |5 | | | | | | | | | |34 |I feel that I have a number of good qualities |1 |2 |3 |4 |5 | 35. I most frequently obtain information about slimming from the following channel (tick ( one only): ( TV ( Radio ( Newspaper ( Magazine ( Internet ( Others (please specify):____________________ Part III We would like to end with a few demographic questions. Please write down the related information or put a tick ( in the appropriate option. 1 |My age is: ______ years | |2 |My weight is: about ______________ pounds (or ______ kg) | |3 |My height is: about ______feet ______inches (or ______ cm) | |4 |How often do you exercise? ______ times per month | |5 |My marital status is: ( Single ( Married ( Widowed ( Divorced ( Separated | |6 |My monthly inocme is: | | |( Below $5000 ( $5001-$9000 ( $9001-$15000 ( $15001-$25000 ( $25001 or above | |7 |The highest level of education I attained: | |( Primary school or below ( Lower secondary ( Upper secondary ( Matriculation | | |( Certificate/Diploma/Higher Diploma/Associate/Bachelor’s Degree ( Master’s Degree ( Ph. D. | ———————– Thank you very much for your assistance! Hello! I am a student of XX University. I am now conducting a survey about body image among Chinese female adulthood. It is grateful if you could take 5 to 10 minutes to complete this questionnaire. There is no right or wrong answer. Your participa tion is voluntary. The information obtained in this study will be used to prepare a research report and no identifying information will be revealed in the dissemination of the results. Thank you.