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Questionnaire : Body Image

Today I would like to ask you some questions about body image and self-esteem issues.



First Name:
Age:
Size:
Height:
Sex:
City & Country:

FYI: I only ask your age, size & height because it will help me get a better overall idea as to what people of different ages and sizes are thinking and feeling. Celebrate yourself at any age, at any size!


How would you describe your body in one or two words?
Have you ever said you "hate" your body or any body part?
Yes No
Why?
When did/do you most love your body?
Think back – what is your first memory when someone else told you your body or any part of you was imperfect?
What did he/she say or do?
How did that make you feel?
What body part do you most like?
Why?
Please state 5 great things about your body:
How often do you weigh yourself?
What is the one thing you could do to love your body more?
What do you think influences your opinion of your body the most?

  my friends
  my family
  my boyfriend/girlfriend/spouse/partner
  tv and the media
  internet
  the perceptions I think others have of my body
  myself
  other
If I could give advice to a small child about growing up with a positive body image I would say:
Any other comments or thoughts?
(Maximum characters: 300)
You have characters left.
Please check here to submit your answers. I look forward to hearing what you are thinking and understanding what you are feeling. By clicking here, you are agreeing to possibly let me share your comments with others. My wish is to share this information in a positive way in order for all of us to have a more positive perception of our bodies. If you feel more comfortable leaving your name blank, please do so – I would rather receive your information than not. Thanks so much for taking the time to share with me!