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What is your gender?
 
Male
 
Female
 
 
 
What is your age?
   
 
 
 
Where do you live?
   
 
 
 
How many times do you go to the bathroom just to look at your self in a day?
 
None
 
O-5
 
5-10
 
10+
 
 
 
Are you confident in the body you are in?
   
 
 
 
Is there something about yourself that you would change?
   
 
 
 
If you were given any operation on yourself what would you change?
   
 
 
 
Would you get up from bed and go straight to school without getting ready?
 
Yes
 
No
 
 
 
Do you value yourself as a confident person in the way you look physically?
 
Yes
 
No
 
 
 
How strongly do you think looks matter in society?
   
 
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