Name: | Date: | |
Please read each question carefully and circle the answer that is true for you. Also write in answers where indicated. | ||
| Yes | No |
| Yes | No |
• If yes: Please list the body areas you don't like: | ||
Examples of disliked body areas include: your skin (for example, acne, scars, wrinkles, paleness, redness); hair; the shape or size of your nose, mouth, jaw, lips, stomach, hips, etc; or defects of your hands, genitals, breasts, or any other body part. | ||
NOTE: If you answered "No" to either of the above questions, you are finished with this questionnaire. Otherwise continue. | ||
| Yes | No |
| ||
| Yes | No |
| Yes | No |
• If yes: Describe how: | ||
| Yes | No |
• If yes: What are they? | ||
| Yes | No |
• If yes: What are they? | ||
| ||
(a) Less than 1 hour a day (b) 1 to 3 hours a day (c) More than 3 hours a day |
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟