LBJ INSECURITIES SURVEY

1
What is your NAME/ INSTAGRAM @?Leave blank for anonymous. Fill out your Instagram @ if you're happy to be contacted.
2
What GENDER do you identify as?* This field is required.This will customise the questions.
Male
Female
Other
3
What COUNTRY are you from?* This field is required.
Australia
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
4
Overall, how CONFIDENT are you with your body?* This field is required.
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
5
What AGE range are you in?* This field is required.
Teens
20s
30s
40s
50s
60+
6
(M) Do you have an insecurity about your BODY SHAPE?* This field is required.
Yes - Too Heavy
Yes - Too Light
Yes - Too Tall
Yes - Too Short
Yes - Too Muscular
Yes - Not Muscular Enough
No
Other
7
(F) Do you have an insecurity about your BODY SHAPE?* This field is required.
Yes - Too Heavy
Yes - Too Light
Yes - Too Tall
Yes - Too Short
Yes - Too Muscular
Yes - Not Muscular Enough
No
Other
8
(O) Do you have an insecurity about your BODY SHAPE?* This field is required.
Yes - Too Heavy
Yes - Too Light
Yes - Too Tall
Yes - Too Short
Yes - Too Muscular
Yes - Not Muscular Enough
No
Other
9
(M) Do you have an insecurity about the HAIR ON YOUR HEAD?* This field is required.
Yes - Amount (bald/balding/thinning)
Yes - Colour (greying)
Yes - Type (too frizzy/curly/straight)
No
Other
10
(F) Do you have an insecurity about the HAIR ON YOUR HEAD?* This field is required.
Yes - Amount (bald/balding/thinning)
Yes - Colour (greying)
Yes - Type (too frizzy/curly/straight)
No
Other
11
(O) Do you have an insecurity about the HAIR ON YOUR HEAD?* This field is required.
Yes - Amount (bald/balding/thinning)
Yes - Colour (greying)
Yes - Type (too frizzy/curly/straight)
No
Other
12
(M) Do you have an insecurity about your FACIAL HAIR?* This field is required.
Yes - Amount (too much/little)
Yes - Colour (greying)
Yes - Location (growing from somewhere you'd prefer it not)
No
Other
13
(F) Do you have an insecurity about your FACIAL HAIR?* This field is required.
Yes - Amount (too much/little)
Yes - Colour (greying)
Yes - Location (growing from somewhere you'd prefer it not)
No
Other
14
(O) Do you have an insecurity about your FACIAL HAIR?* This field is required.
Yes - Amount (too much/little)
Yes - Colour (greying)
Yes - Location (growing from somewhere you'd prefer it not)
No
Other
15
(M) Do you have an insecurity about your SKIN IN GENERAL?* This field is required.
Yes - Pigmentation (rosesha/birth mark/port wine stain/vitiligo)
Yes - Blemishes (scars from surgery/injury/self inflicted)
Yes - Blemishes (stretch marks)
Yes - Blemishes (cellulite)
Yes - Lines & Wrinkles
Yes - Excess (weightloss)
Yes - Excess ("double chin"/"tuckshop lady arms")
Yes - Tattoo Related (unwanted/bad)
Yes - Freckles
Yes - Warts/Moles
No
Other
16
(F) Do you have an insecurity about your SKIN IN GENERAL?* This field is required.
Yes - Pigmentation (rosesha/birth mark/port wine stain/vitiligo)
Yes - Blemishes (scars from surgery/injury/self inflicted)
Yes - Blemishes (stretch marks)
Yes - Blemishes (cellulite)
Yes - Lines & Wrinkles
Yes - Excess (weightloss)
Yes - Excess ("double chin"/"tuckshop lady arms")
Yes - Tattoo Related (unwanted/bad)
Yes - Freckles
Yes - Warts/Moles
No
Other
17
(O) Do you have an insecurity about your SKIN IN GENERAL?* This field is required.
Yes - Pigmentation (rosesha/birth mark/port wine stain/vitiligo)
Yes - Blemishes (scars from surgery/injury/self inflicted)
Yes - Blemishes (stretch marks)
Yes - Blemishes (cellulite)
Yes - Lines & Wrinkles
Yes - Excess (weightloss)
Yes - Excess ("double chin"/"tuckshop lady arms")
Yes - Tattoo Related (unwanted/bad)
Yes - Freckles
Yes - Warts/Moles
No
Other
18
(M) Do you have an insecurity about your EYES?* This field is required.
Yes - Size (large/small)
Yes - Alignment (lazy eye/etc)
Yes - Spacing (far apart/close together)
Yes - Colour
Yes - Vision (insecure about wearing glasses/contacts)
No
Other
19
(F) Do you have an insecurity about your EYES?* This field is required.
Yes - Size (large/small)
Yes - Alignment (lazy eye/etc)
Yes - Spacing (far apart/close together)
Yes - Colour
Yes - Vision (insecure about wearing glasses/contacts)
No
Other
20
(O) Do you have an insecurity about your EYES?* This field is required.
Yes - Size (large/small)
Yes - Alignment (lazy eye/etc)
Yes - Spacing (far apart/close together)
Yes - Colour
Yes - Vision (insecure about wearing glasses/contacts)
No
Other
21
(M) Do you have an insecurity about your NOSE?* This field is required.
Yes - Size (large/small)
Yes - Shape (bent/broken)
No
Other
22
(F) Do you have an insecurity about your NOSE?* This field is required.
Yes - Size (large/small)
Yes - Shape (bent/broken)
No
Other
23
(O) Do you have an insecurity about your NOSE?* This field is required.
Yes - Size (large/small)
Yes - Shape (bent/broken)
No
Other
24
(M) Do you have an insecurity about your TEETH?* This field is required.
Yes - Colour (stain/dead)
Yes - Missing (one or multiple)
Yes - Alignment (crooked/twisted)
Yes - Alignment (overbite/underbite)
No
Other
25
(F) Do you have an insecurity about your TEETH?* This field is required.
Yes - Colour (stain/dead)
Yes - Missing (one or multiple)
Yes - Alignment (crooked/twisted)
Yes - Alignment (overbite/underbite)
No
Other
26
(O) Do you have an insecurity about your TEETH?* This field is required.
Yes - Colour (stain/dead)
Yes - Missing (one or multiple)
Yes - Alignment (crooked/twisted)
Yes - Alignment (overbite/underbite)
No
Other
27
(M) Do you have an insecurity about your LIPS?* This field is required.
Yes - Size (thin)
Yes - Size (thick)
No
Other
28
(F) Do you have an insecurity about your LIPS?* This field is required.
Yes - Size (thin)
Yes - Size (thick)
No
Other
29
(O) Do you have an insecurity about your LIPS?* This field is required.
Yes - Size (thin)
Yes - Size (thick)
No
Other
30
(M) Do you have an insecurity about your EARS?* This field is required.
Yes - Size (big/small)
Yes - Shape (stick out/long lobes)
No
Other
31
(F) Do you have an insecurity about your EARS?* This field is required.
Yes - Size (big/small)
Yes - Shape (stick out/long lobes)
No
Other
32
(O) Do you have an insecurity about your EARS?* This field is required.
Yes - Size (big/small)
Yes - Shape (stick out/long lobes)
No
Other
33
(F) Do you have an insecurity about your BREASTS?* This field is required.
Yes - Size (large)
Yes - Size (small)
Yes - Symmetry (uneven)
Yes - Perkiness
Yes - Nipple Related (areola size, colour, etc)
Yes - Markings (scars/stretch marks)
No
Other
34
(M) Do you have an insecurity about your BUM region?* This field is required.
Yes - Size (large)
Yes - Size (small)
Yes - Shape (flat)
Yes - Blemishes (scars/stretch marks/cellulite)
Yes - Excess Hair
Yes - Hips
No
Other
35
(F) Do you have an insecurity about your BUM region?* This field is required.
Yes - Size (large)
Yes - Size (small)
Yes - Shape (flat)
Yes - Blemishes (scars/stretch marks/cellulite)
Yes - Excess Hair
Yes - Hips
No
Other
36
(O) Do you have an insecurity about your BUM region?* This field is required.
Yes - Size (large)
Yes - Size (small)
Yes - Shape (flat)
Yes - Blemishes (scars/stretch marks/cellulite)
Yes - Excess Hair
Yes - Hips
No
Other
37
(M) Do you have an insecurity about your GENITALS?* This field is required.
Yes - Penis Length
Yes - Penis Girth
Yes - Blemishes (bumps/warts/scars)
Yes - Testicles (size/symmetry/perkiness)
Yes - Hair (excess)
Yes - Colour (vitiligo/darker pigment)
No
Other
38
(F) Do you have an insecurity about your GENITALS?* This field is required.
Yes - Clitoris Size
Yes - Labia Size/Length
Yes - Blemishes (bumps/warts/scars)
Yes - Odour
Yes - Hair (excess)
Yes - Colour (vitiligo/darker pigment)
No
Other
39
(O) Do you have an insecurity about your GENITALS?* This field is required.
Yes - Size (labia/penis)
Yes - Blemishes (bumps/warts/scars)
Yes - Odour
Yes - Hair (excess)
Yes - Colour (vitiligo/darker pigment)
No
Other
40
(M) Do you have an insecurity about your ABDOMEN?* This field is required.
Yes - Too Large
Yes - Too Small
Yes - Too Muscular
Yes - Not Muscular Enough
Yes - Hair (excess)
Yes - Blemishes (scars/stretch marks)
Yes - Belly Button
Yes - Excess Skin (weight loss)
No
Other
41
(F) Do you have an insecurity about your ABDOMEN?* This field is required.
Yes - Too Large
Yes - Too Small
Yes - Too Muscular
Yes - Not Muscular Enough
Yes - Hair (excess)
Yes - Blemishes (scars/stretch marks)
Yes - Belly Button
Yes - Excess Skin (weight loss)
No
Other
42
(O) Do you have an insecurity about your ABDOMEN?* This field is required.
Yes - Too Large
Yes - Too Small
Yes - Too Muscular
Yes - Not Muscular Enough
Yes - Hair (excess)
Yes - Blemishes (scars/stretch marks)
Yes - Belly Button
Yes - Excess Skin (weight loss)
No
Other
43
(M) Do you have an insecurity about your LEGS?* This field is required.
Yes - Length (long or short)
Yes - Thighs (large/no gap/etc)
Yes - Feet Size (large)
Yes - Feet Size (small)
Yes - Toes (hammertoe/bunions/etc)
Yes - Hair (excess/sparse/ingrown)
No
Other
44
(F) Do you have an insecurity about your LEGS?* This field is required.
Yes - Length (long or short)
Yes - Thighs (large/no gap/etc)
Yes - Feet Size (large)
Yes - Feet Size (small)
Yes - Toes (hammertoe/bunions/etc)
Yes - Hair (excess/sparse/ingrown)
No
Other
45
(O) Do you have an insecurity about your LEGS?* This field is required.
Yes - Length (long or short)
Yes - Thighs (large/no gap/etc)
Yes - Feet Size (large)
Yes - Feet Size (small)
Yes - Toes (hammertoe/bunions/etc)
Yes - Hair (excess/sparse/ingrown)
No
Other
46
Do you have any other insecurity about your BODY not already listed?leave blank if no
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: