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  • What age range do you fall under?
0-15 16-18 18-21 22-25 26-40 41+
  • What setting is your primary residence located in?
City Suburban Rural


  • What gender do you identify as?
Male Female Non-binary


  • Please specify your ethnicity.
Caucasian African


Latino or Hispanic Asian Native American Native Hawaiian or

Pacific Islander

Two or More Other
  • What is your relationship status?
Single In a relationship Engaged Married Divorced Widowed


  • How much do you spend on social media per day*?
Half an hour 1-3 hours 3-5 hours More than 5 hours



7) How often do you interact (have dialogue)with other peopleusing social media+?

Daily Weekly Monthly Yearly Never



8) While viewing other people’s profile do you compare yourself with them?

Always Often Sometimes Rarely Never


9) Does the number of likes on your picture or status affect you?

Yes No Sometimes



10) Why do you use social media*?




Medium of


Information Fulfill





Other (please




11) Have you ever gotten cosmetic surgery?

Yes No (skip question 11)


12) Which part of your body have you had cosmetic surgery on? (select all that applies)

Face Neck Below Neck & Above Waist Below Waist


13) Have you ever considered getting plastic surgery?

Yes No (skip question 13 &14)


14) Which part of your body have you considered getting cosmetic surgery on? (select all that applies)

Face Neck Below Neck & Above Waist Below Waist

15) What is preventing you from pursuing cosmetic surgery?

Money Social Stigma Medical Concerns Other (please specify)






Part 2

Instructions: Below is a list of statements dealing with your general

feelings about yourself. Please indicate the level of your satisfaction on a

scale of 1-10 with 10 being the highest level of satisfaction.


  1 2 3 4


5 6 7 8 9 10
1. On the whole, I am satisfied with myself.


2. At times I think I am no good at all.


3. I would like to be more attractive in my “selfies.”


4. I feel like my body type is accepted in society.


5. I am satisfied with my body type.


6. If money or medical issues weren’t a problem, I would change something on my body.


7. I feel that I’m a person of worth, at least on an equal plane

with others.


8. If I changed something on my body I would consider myself more attractive


9. I feel self-conscious when I look at models/influencers on social media.


10. I take a positive attitude toward myself.








*Social media includes but is not limited to Instagram, Facebook, Twitter, YouTube, Tumblr and Snapchat.

Cosmetic surgery was defined as surgery without a recommendation and referral by a physician because of deformities, trauma, or other medical indications.

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