Body Image and the Media
 This survey is completely anonymous, so PLEASE be honest when answering the questions... And, don't forget to have fun while completing the survey!
1. What gender are you?
        Male
        Female
2. How old are you
        18 or Under
        19-21
        21-24
        25-29
        30-34
        35-39
        40-44
        45-49
        50+
3. What Race/Ethnicity are you?
        Caucasian
        African-American
        Asian-American
        Hispanic
        Native-American
        Other
4. If you put "other" on question 3 please indicate what race/ethnicity you are. 
5. What economic class do you consider yourself?
        Upper class
        Upper middle class
        Middle class
        Lower middle class
        Lower class
6. What is your level of education (if you are currently a student please check the box that corresponds with the degree you are currently pursuing)?
        None
        High-School
        2 year degree
        4 year degree
        Graduate degree
        Vocational studies
7. Do you exercise regularly (this means 3 or more times a week)?
        Yes
        No
8. Are you currently in an exclusive relationship (this can be dating or married)?
        Yes
        No
9. On average, how many hours per day do you read the newspaper
        0-1
        1-2
        2-3
        3-4
        5+
10. On average, how many hours per day do you listen to the radio?
        0-1
        1-2
        2-3
        3-4
        5+
11. On average, how many hours per day do use the Internet?
        0-1
        1-2
        2-3
        3-4
        5+
12. On average, how many hours per week do you read magazines?
        0-1
        1-2
        2-3
        3-4
        5+
13. On average, how many hours per day do you watch television?
        0-1
        1-2
        2-3
        3-4
        5+
14. What is your preferred media method for receiving your daily news and entertainment?
 Please type the following media in order of MOST preferred to LEAST preferred: Newspaper, Radio, Internet, Magazines, Television.
        
15. What is your main purpose when you read a newspaper?
        Entertainment/Fun
        News
        Work-School Related
        Self-help/Improvement
16. What is your main purpose for listening to the radio?
        Entertainment/Fun
        News
        Work-School Related
        Self-help/Improvement
17. What is your main purpose when using the internet?
        Entertainment/Fun
        News
        Work-School Related
        Self-help/Improvement
18. What is your main purpose when reading a magazine?
        Entertainment/Fun
        News
        Work-School Related
        Self-help/Improvement
19. What is your main purpose when watching television?
        Entertainment/Fun
        News
        Work-School Related
        Self-help/Improvement
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20. Would you ever consider surgically altering your body (plastic surgery)?
        Already have
        Strongly consider
        Maybe
        Never consider
21. Are you currently on a special diet?
        Yes
        No
22. If you said "yes" to the special diet, is it for health or weight loss?
        Health
        Weight loss
23. If you said "no" to the special diet question, do you have plans to go on a diet in the future?
        Yes
        No
24. Judge this statement:
 "I would be happier if I were thinner".
        Strongly agree
        Somewhat agree
        Agree
        Somewhat disagree
        Strongly disagree
25. Have you ever suffered from an eating disorder?
        Yes
        No
26. Most models in the media sources I use are:
        Overweight
        Just right
        Too skinny
        Don't know
27. I am currently satisfied with my physical image:
        Not at all
        Somewhat satisfied
        Satisfied
        Very satisfied
        Extremely satisfied

Body Image and the Media Survey
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