This document contains a body image questionnaire with questions about demographic information, features of the body someone dislikes or wants to improve, how much time they spend thinking about those features, how much distress the features cause, and how noticeable the person feels the features are to others. The questionnaire aims to get information about concerns with physical appearance and gauge interest in potential cosmetic procedures.
This document contains a body image questionnaire with questions about demographic information, features of the body someone dislikes or wants to improve, how much time they spend thinking about those features, how much distress the features cause, and how noticeable the person feels the features are to others. The questionnaire aims to get information about concerns with physical appearance and gauge interest in potential cosmetic procedures.
This document contains a body image questionnaire with questions about demographic information, features of the body someone dislikes or wants to improve, how much time they spend thinking about those features, how much distress the features cause, and how noticeable the person feels the features are to others. The questionnaire aims to get information about concerns with physical appearance and gauge interest in potential cosmetic procedures.
This document contains a body image questionnaire with questions about demographic information, features of the body someone dislikes or wants to improve, how much time they spend thinking about those features, how much distress the features cause, and how noticeable the person feels the features are to others. The questionnaire aims to get information about concerns with physical appearance and gauge interest in potential cosmetic procedures.
Single Separated/Divorced Married or cohabiting Widowed (living together)
If single, separated, divorced, or widowed, are you currently in a long-term relationship?
Yes No
5) Current Employment Tick one box
Unemployed Long-term sick leave Employed or Self-employed Retired
Student (Full-time) Homemaker2
6) Please study this example before completing question 6. In a moment, we will ask you to
describe the feature(s) of your body which you dislike or would like to improve. If you want to
improve more than one feature, please list all the features and tick the appropriate box if you are
seeking a cosmetic or dermatological procedure for that feature either now or in the future. We
shall refer to all such treatments as ‘procedures’. Please note, the 1st feature should be the
feature you are most concerned about. This is an example of a woman whose main worry was her nose and who was concerned to a lesser extent by her skin and bottom. She is currently seeking a procedure to her skin.
7) Features Causing Concern
Please describe the feature(s) of your body, which you dislike or would like to improve and tick the box if you are seeking a cosmetic or dermatological
procedure for the feature either now or in the future. Please tick the appropriate
box.
1st Feature
Nose is too crooked with a bump Nose is too crooked with a bump
Procedure sought
a) Now b) Future c) Not desire any procedure
2nd Feature
Blemishes and acne scars on face Blemishes and acne scars on face
Procedure sought
a) Now b) Future c) Not desire any procedure
3rd Feature
Bottom is too big
Procedure
a) Now b) Future c) Not desire any procedure
8) On an average day, how many minutes or hour(s) do you currently spend thinking about your
feature(s)? Please add up all the time that your features are at the forefront of your mind and
make the best estimate.
_____________ minutes or ______________ hour(s) a day.
9) Please read the next set of questions below carefully and circle the number which best describes
the way that you feel about your feature(s). Please read the labels carefully to ensure you are circling the number that reflects how you feel because some of the answers are worded in a reverse order.
10) How often do you deliberately check your feature(s)? Not accidentally catch sight of it.
Please include looking at your feature in a mirror or other reflective surfaces like a shop window
or looking at it directly or feeling it with your fingers.
13) If you have a partner, how much does your feature(s) currently have an effect on your relationship with an existing partner? If you do not have a partner, how much does it have an
18) How noticeable do you feel your feature is to other people (if you do not camouflage yourself e.g. with clothes, padding and/or makeup) and the feature has not been pointed out to them)?
a. Please specify the 1st feature you are rating (this should be the feature you are most concerned about) _______________________________
