1. Are you very concerned about the appearance of some part of your body, which you consider especially unattractive?
2. If yes, do these concerns preoccupy you? That is, you think about them a lot and they're hard to stop thinking about?
3. Has your defect often caused you a lot of distress, torment or pain? How much?
Mild, and not too disturbing
Moderate and disturbing, but still manageable
Severe, and very disturbing
4. Has your defect caused you impairment in social, occupational or other important areas of functioning? How much?
Mild interference, but overall performance not impaired
Moderate, definite interference, but still manageable
Severe, causes substantial impairment
5. Has your defect often significantly interfered with your social life?
6. Has your defect often significantly interfered with your school work, your job, or your ability to function in your role?
7. Are there things you avoid because of your defect?
The presented answer sheet is not an original form and is not intended for printing or use as a handout.