Confidence and Your Body Survey Question Title * 1. How would your rate your general confidence level? Very high High Average Low Very Low Question Title * 2. What percentage of the time do you feel confident? 0 100 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 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) Question Title * 4. How would you describe your body? Obese Overweight Average Thin Underweight Other (please specify) Question Title * 5. What percentage of the time does your body image affect your confidence level?' 0 100 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 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.' Question Title * 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) Question Title * 8. What part of your body do you feel the least confident about? Hair Face Figure Arms Legs Everything Nothing Other (please specify) Question Title * 9. What part of your body do you feel most confident about? Hair Face Figure Arms Legs Everything Nothing Other (please specify) Question Title * 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) Question Title * 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) Question Title * 12. What is your age range? Under 18 18-24 25-34 35-44 45-54 55-64 65+ Question Title * 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) Question Title * 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 Question Title * 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 Question Title * 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 Done