Social Media and Mental Health Questionnaire
The purpose of this questionnaire is to collect and assess high school students’ social
media usage, and how it impacts body image and self-esteem. All information that is
gathered will be utilized for the purposes of this study and will be anonymous and kept
confidential. Your participation is appreciated as it may help bring mental health
education to your school.
Section 1:
Please check one answer for each of the questions provided unless otherwise stated.
What gender do you identify with? o Male o Decline to answer
o Female
What grade are you in? o 9th grade o 12th grade
o 10th grade o Other:_____
o 11th grade
Do you have any image based social o Yes o No
media accounts? Ex. Instagram, (If no, jump to section 3)
Snapchat, Twitter, etc.
On average, how much time do you o Less than 30 minutes o 2-3 hours
spend on social media each day? o 30-60 minutes o More than 3 hours
o 1-2 hours
Who do you follow on social media? o Friends/Family o News/Entertainment
(Select all that apply). o Celebrities/Models o Gaming Accounts
o Athletes/Fitness o Funny Accounts
o Influencers/Bloggers o Other ___________
o Animals/Pets
What kind of images do you mostly
view on social media? ____________________________________________
Section 2:
Please read the following below and indicate how it best fits you overall.
Somewhat
To a Great
Very Little
Not at All
Extent
Please check one answer for each of the questions
I use social media to see what others think about how I look. o o o o
I use social media to compare my body/shape with other people’s o o o o
body/shape.
I use social media to check how others look. o o o o
I use social media to see what others think about my photos o o o o
From Motivation to Use Social Media for Body Comparison (MEIS) questionnaire. Developed by Puglia, D. R. (2017).
Retrieved from https://cdr.lib.unc.edu/downloads/n009w303t
Section 3:
The following statements describe how some people feel about their appearance. Please read
each statement and use the scale to indicate how often you have felt this way in the PAST SIX
MONTHS.
Sometimes
Always
Rarely
Never
Often
Please check one answer for each of the questions
I like what I look like in pictures o o o o o
I like what I see when I look in the mirror o o o o o
I am as nice looking as most people o o o o o
I wish I looked better o o o o o
I worry about the way I look o o o o o
From Exploring the Utility of Community-Generated Social Media Content for Detecting Depression: An Analytical Study
on Instagram. Developed by the Ricard, B.J., Marsch L. A., Crosier, B., & Hassanpour, S.(2018). Retrieved from
https://www.jmir.org/2018/12/e11817/
Section 4:
For the following questions, please identify the number of days you have been affected by each
of the feelings.
More than half the
Nearly every day
Not true at all
Half the days
Several days
How often during the past 2 weeks were you bothered by…
days
(please check one answer for each of the questions)
Little interest or pleasure in doing things o o o o o
Feeling down, depressed, or hopeless o o o o o
Trouble falling or staying asleep, or sleeping too much o o o o o
Feeling tired or having little energy o o o o o
Poor appetite or overeating o o o o o
Feeling bad about yourself, or that you are a failure, or have let o o o o o
yourself or your family down
Trouble concentrating on things, such as reading or watching TV o o o o o
Moving or speaking so slowly that other people could have noticed. o o o o o
Or the opposite- being so fidgety or restless that you have been
moving around more than usual
From the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MDPHQ). The PHQ was
developed by Drs. Spitzer, R. L., Williams, J. B. W., Kroenke, K., and colleagues (1999). Retrieved from
https://www.sciencedirect.com/science/article/pii/S0165032708002826
Thank you for completing our survey. Your time is appreciated! J
