Questionnaire
Questionnaire
- 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
American |
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*?
| Building
relationships
|
Medium of
communication |
Information Fulfill
|
affiliation
needs
|
Other (please
specify)
|
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.
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| 2. At times I think I am no good at all.
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| 3. I would like to be more attractive in my “selfies.”
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| 4. I feel like my body type is accepted in society.
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| 5. I am satisfied with my body type.
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| 6. If money or medical issues weren’t a problem, I would change something on my body.
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| 7. I feel that I’m a person of worth, at least on an equal plane
with others.
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| 8. If I changed something on my body I would consider myself more attractive
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| 9. I feel self-conscious when I look at models/influencers on social media.
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| 10. I take a positive attitude toward myself.
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*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.
