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  1. 1. CONSENT FORM FOR ‘BODY MIRRORED’Thank you for taking the time to give your consent and participate in theresearch for my Final Year Project at Brunel University. By the end of the year, Iplan to have created a motion graphics based artefact that provides users withinformation and statistics about the diagnosis, symptoms and treatment of BodyDysmorphic Disorder. It is essential that awareness is raised about thiscondition.In order to do this, I need your help in providing me with primary data andinformation that I can later analyse and draw my own conclusions from. Byagreeing to participate, you will be required to spend some time answeringquestions on a number of different topics, ranging from your feelings towardsyour physical appearance, weight and body shape, as well as your opinions aboutwomen featured within the media. The whole process should take no longer than20 minutes, and you are able to withdraw from the questionnaire at any time. Ifyou would also prefer not to answer a question, you can do this by simply leavingit blank. You will remain completely anonymous throughout, and will not benamed under any circumstances.By signing this consent form, you understand and agree with the conditions Ihave stated above.Many thanks for participating in my questionnaire. If you have any questions,please feel free to contact me.Lucy CorneliusEmail: 07596284334I _________________________________________ (print name) have read the aboveinformation and have agreed to participate in Lucy Cornelius’ questionnaire. Iunderstand that I can withdraw at any time without providing an explanation,and this decision will not affect my rights.Signed _________________________________________Date _________________________________________
  2. 2. Women and Your Appearance QuestionnairePlease circle which age range you are in: 10- 15 16-21 22-29 30-40 41-50 50+Physical Appearance 1) Please circle, from 1-10 (10 being the most), how satisfied are you with your physical appearance? 1 2 3 4 5 6 7 8 9 10 2) How many times during the day do you choose to check your appearance in a reflective surface? 1 2 3 4 5 6 7 8 9 10+ 3) How important on a scale of 1-10 (10 being the highest) do you think it is to take care of your appearance? 1 2 3 4 5 6 7 8 9 10 4) Which parts of your body do you most like? 5) Have you ever been complimented on one or more of the parts you mentioned above? YES NO 6) If YES, how did this make you feel? Please circle all that are appropriate and add any additional responses you felt towards the compliment. Positive Embarrassed Uncomfortable Flattered Confident 7) Would you ever consider cosmetic surgery? YES NO 8) If YES, which procedure/s would you be willing to have? Please circle all that apply. FACIAL: Face LiftBotox Lips Nose Cheek Implants Chin Eye Lift BODY: Breast Enlargements/Reductions Nipple Correction Stomach Thighs Buttocks Arms
  3. 3. 9) If NO, why not? 10) Do you wear make up? YES NO 11) If YES, whom do you wear it for? Please circle all that apply. Yourself Your Friends The opposite sex 12) Have you ever avoided a social situation due to feeling anxious of the way you look? YES NO 13) Have you ever been clinically diagnosed with depression at any point in your life? YES NOBody Weight and Shape 1) What UK dress size are you? 4 6 8 10 12 14 16 18 20 22+ 2) What do you think the average UK dress size is? 4 6 8 10 12 14 16 18 20 22+ 3) What do you think the average UK dress size should be? 4 6 8 10 12 14 16 18 20 22+ 4) What size do you consider to be overweight? (Assuming women’s height is the average 5ft 6) 4 6 8 10 12 14 16 18 20 22+ 5) What are your feelings towards women who are considered to be overweight? 6) Have you ever pinched a part of your body to see how much excess skin there is? YES NO 7) Do you see your body as being in proportion? YES NO
  4. 4. 8) How would you describe the perfect body? You can refer to celebrities or people in the media.9) Are you aware of the different body shape categories? YES NO10) Out of the body shapes listed below, which would you say you were most like? APPLE (most body weight is carried in the midsection, slim legs, large bust) HOUR GLASS (bust measurement same as hip, proportionally curvy) PEAR (most weight situated on bottom half, larger hips, bum and thighs) TALL / PETITE (5ft 10+ / Under 5ft 3) ATHELTIC (sporty, strong body with very few curves) SLENDER (Slim with small curves) NONE OF THESE11) Have you ever dieted? YES NO12) If YES, why did you choose to? Please circle all that apply. Health Reasons Personal Self Esteem Pressure from 3rd Party13) If YES, were you successful in your diet? YES NO14) Do you wear shape wear/control garments? YES NO15) If YES, which area/s of your body do you wish to make appear slimmer? Please circle all that apply. Stomach Thighs Arms Bum Bust Waist All In One16) Do you own weighing scales? YES NO
  5. 5. 17) If YES, how often do you weigh yourself? Daily Weekly Every 1-6 Months Yearly I never weigh myselfThe Media 1) Can you tell if a model has been airbrushed within the magazines you read? YES NO 2) If YES, what gives it away? 3) Would you prefer to see natural photographs of women in the media that have not been altered in post production? YES NO 4) Have you ever felt pressure to lose weight from reading magazines? YES NO 5) Do you compare yourself to women featured within magazines? YES NO 6) Do you feel sad/anxious/worried when you see women slimmer than you featured in magazines? YES NO 7) Do you feel that the women featured in magazines are a true representation of women in the 21st Century? YES NO Many thanks for taking part in this survey. If you have any questions about the survey and what the information you have provided will be used for, please feel free to contact me at