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Confidence and Your Body Survey
1.
How would your rate your general confidence level?
Very high
High
Average
Low
Very Low
2.
What percentage of the time do you feel confident?
0
100
Clear
3.
What situations do you think have most negatively affected your confidence level?
New job
New school
Weight gain
Weight loss
Pregnancy
Being in a romantic relationship
Moving
Dysfunctional family
Divorce
Abusive relationship
Other (please specify)
4.
How would you describe your body?
Obese
Overweight
Average
Thin
Underweight
Other (please specify)
5.
What percentage of the time does your body image affect your confidence level?'
0
100
Clear
6.
Would you share a story about when you lost or gained confidence in yourself because of how you felt about your body? Please do not include personal information or names.'
7.
Who do you think has affected your confidence about your body the most?
Family members
Romantic partners
My friends
My work colleagues
Society
Other women
No one except myself
Other (please specify)
8.
What part of your body do you feel the least confident about?
Hair
Face
Figure
Arms
Legs
Everything
Nothing
Other (please specify)
9.
What part of your body do you feel most confident about?
Hair
Face
Figure
Arms
Legs
Everything
Nothing
Other (please specify)
10.
Please check all the things you have previously done to build confidence.
Counseling
Affirmations
Talked with close friends
Talked with family members
Make-over
Changed jobs or schools
Ended or started romantic relationships
Joined an organization or peer group
Joined a Mastermind/peer group
Other (please specify)
11.
Please check all areas that would help you gain additional confidence.
Get counseling
Use affirmations
Talk with close friends
Get a make-over
Switch jobs
End or start a romantic relationship
Join an organization l
Join a Mastermind/peer group
Other (please specify)
12.
What is your age range?
Under 18
18-24
25-34
35-44
45-54
55-64
65+
13.
What is your ethnicity?'
White or Caucasian
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Other
Other (please specify)
14.
Which of the following best describes your current relationship status?
Married
Widowed
Divorced
Separated
In a domestic partnership or civil union
Single, but cohabiting with a significant other
Single, never married
15.
What is the highest level of education you have completed?
Graduated from high school
2 years of college
Graduated from college
Completed graduate school
16.
What is your total household income?
Less than $20,000
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 or More
Not Applicable