1. Real Girls Survey
Please complete this survey. It contains questions about your view of yourself, media,
and your relationships.
Background
Age: ___ Grade: ___
Mother’s Education: ________ Father’s Education: ________
Live with: __mother only; __father only; __both parents; __other
Typical grades: reading: A, B, C, D, F; math: A, B, C, D, F
Media Literacy
How many hours do you spend listening to or watching the following media each day?
__television; __radio; __CD player/iPod; __Internet
How many hours do you spend talking to family and/or friends (in person)? ______
What is your favorite TV show? ___________________________
What is your favorite magazine? __________________________
What is your favorite movie? _____________________________
What is your favorite website? ____________________________
What is your favorite song? ______________________________
What is your favorite video game? _________________________
What is your favorite book? ______________________________
Self-Concept

2. How often are you physically active? ___minutes/day
Do you believe that you are over weight? __yes; __no
Are you currently trying to lose weight? __yes; __no
If yes, how? __exercise; __ pills; __fasting; __laxatives; __vomiting; __reduced calories
What do you worry about? __being pressured to have sex; __having friends; __fitting in;
__being pretty enough; __being smart enough; __graduating from high school
Do you have a boyfriend? __yes; __no
If yes, how old is he? ___
Time spent together each week? ___hours
Are your friends sexually active? __yes; __some; __no
Do your friends drink alcohol? __yes; __some; __no
Do your friends use tobacco? __yes; __some; __no
Do your friends use drugs? __yes; __some; __no
Healthy Relationship
How do people treat each other in a healthy relationship?
_____________________________________________________________________________
_________________________________________________________________
Please write True or False for the following items.
__It is against my values to have sex before I am married.

3. __It is against one or both of my parents’ values for me to have sex before I am married.
__Teens who have been dating for a long time should have sex if they want to.
Please circle the response that is most like you.
I am happy with who I am.
Never Sometimes Often Always
My friends are smarter or prettier than I am.
Never Sometimes Often Always
I want to look like the girls in magazines.
Never Sometimes Often Always
I compare myself to fashion models.
Never Sometimes Often Always
Women in the media seem like real women.
Never Sometimes Often Always
I let people take advantage of me.
Never Sometimes Often Always