Males – 17, Females - 13
1. do you smoke cigarettes?
yes
males
0
females 0
sometimes
3
2
no
14
11
2. is active movement important for your psychical well-being?
yes, often
14
11
sometimes
3
1
almost never
0
1
3. do you like to eat in pleasant enviroment with pople you like?
yes, often
14
12
sometimes
3
1
almost never
0
0
4. do you practice massages, relaxation techniques, sauna (either with the specialist or
without)?
yes
rarely
no
4
10
3
3
8
2
5. are you satisfied with your body?
yes
9
8
partly
6
4
no
2
1
6. do you think, that your body could be different, better?
a) no
0
0
b) sometimes
13
12
c) often
4
1
d) I would like to have different body, or sex
0
0
7. do you practice reducing diet?
a) I have never tried it
8
6
b) I have tried it once c) I have tried it many times
7
2
4
3
8. are you interested in your dreams?
yes, often
sometimes
4
8
5
7
no
5
1
9. do you feel discomfort, when people which are close to you, kiss you or hug you when
meeting you?
yes
1
0
sometimes
2
2
no
14
11
10. do you praktice foreplay in sex?
yes
13
11
sometimes
3
0
no
1
2
(2 no answer)
11. do you think, that your body represents fully your nature, or character?
yes
4
5
partly
11
7
no
2
1
12. do you ignore or bagatelize your illness, when you fall ill?
yes, often
6
3
only sometimes
4
8
no
7
2
13. have you got problems with underweight or overweight?
yes, often
sometimes
no
1
2
14
1
3
9
14. do you get drunk? (so you cannot control what you are doing, you are doing things
you wouldn´t normally do and which are not quite accetable, you feel sick after, or
somebody reproaches you for drinking)
yes, often
5
2
sometimes
9
5
no
3
6
15. have you got guilty feelings when consuming food, sweets or alcohol?
yes, often
4
2
sometimes
4
8
no
9
3
16. are you able to relax?
yes
14
8
sometimes
3
5
no
0
0
17. do you experience feelings of anger, despair or discontent, when you have physical
problems, or some physical processes doesn´t function as they should?
yes, often
2
3
sometimes
10
9
no
5
1
18. do you have unpleasant feelings when you are naked in the presence of other people?
(in cloak-room, with your partner etc.)
yes, often
2
1
sometimes
1
4
no
14
8
19. is healthy eating important for you?
yes, often
10
9
sometimes
6
3
no
1
1
20. does it happens to you, that you spend long moments in front of the mirror with
misdoubt concerning you appearance?
yes, often
0
1
sometimes
0
2
no
17
10
21. are you able to express your emotions in a good manner?
yes
7
7
partly
8
6
no
2
0
22. do you think you are attractive?
yes
6
5
partly
10
7
no
1
1
23. did you ever have sexual intercourse against your will?
yes, repeatedly
0
0
yes
2
1
no
15
12
24. do you think, that physical appearance and physical (nonverbal) display show
psychical qualities of people?
yes
partly
no
6
11
0
3
9
1
25. do you think, that it is bad to express weakness, for example by crying?
yes
4
0
partly
2
1
no
11
12
26. are you promiscuite (changing partners mainly for sexual satisfaction)?
yes, often
0
0
sometimes
6
1
no
11
12
27. do you have problems with sleep? (with falling asleep, often waking up etc.)
yes, often
2
0
sometimes
10
2
no
5
11
28. does it happens to you, that you feel ashamed, discontent or in anger when
menstruating? (women)
yes, often
2
sometimes
3
no
8
does it happens to you, that you feel effeminate in unpleasant way, or somebody
indicate that to you? (men)
yes, often
0
sometimes
1
no
16
29. do you feel disgust or shame on subject of excretion?
almost allways
0
0
sometimes
1
3
no
16
10
30. do you experience moments of peace, without need to think of future or past, and
without use of any psychoactive drugs?
yes, often
8
8
sometimes
8
4
no
1
1
31. do you experience feelings of full satisfaction in the course of coitus?
yes, often
12
5
sometimes
4
5
no
1
1
(2 no answer)
32. do you have a place, where you like to dwell and where you fell you belong to? (it can
also be place in a „family circle“ etc.)
yes
15
9
partly
1
4
no
1
0
33. does it happens to you, that you feel your body as insensitive or numb, without any
medical reasons?
yes, often
0
0
sometimes
4
4
no
13
9
34. are you satisfied with your nature? (character, temperament)
yes
10
9
partly
6
4
no
1
0
35. are you satisfied with the moveability of your body?
yes
11
10
partly
2
2
no
4
1
36. are you satisfied with your physical strength?
yes
10
7
partly
5
5
no
2
1
37. do you overeat yourself?
yes, often
0
0
sometimes
9
7
no
8
6
38. does it happens to you, that you don´t take your usual meal because of the lack of
time?
yes, often
3
1
sometimes
10
8
no
4
4
39. do you experience feeling of satisfaction and delight, when behaving spontaneously?
yes, often
7
9
sometimes
10
4
no
0
0
40. do you experience feelings of happiness or peace, connected with feelings of physical
delight?
yes, often
9
10
sometimes
8
3
no
0
0
41. do you agree with the statement, that „illness includes a mesage for us?“
yes
11
7
partly
4
4
no
2
2
42. are you able to dress yourself up in a way, that your dress is nice, comfortable,
adequate for the situation, your mood and physical appearance?
yes
13
13
rarely
3
0
no
1
0
43. are you exhausted ?
yes, often
5
0
sometimes
10
10
no
2
3
44. have you got tendencies for hazardous (risky) or impulsive behaviour?
yes, often
1
1
sometimes
5
3
no
11
9
sometimes
5
2
rarely or never
10
11
45. have you got injuries?
yes, often
2
0
46. have you got feelings of physical weakness without any outer cause?
yes, often
2
0
sometimes
4
8
no
11
5
47. do you think, that human body is only a complex machine (mechanism)?
yes
6
1
partly
1
4
no
10
8
48. have you got sometimes feelings, as if you was looking at the world through some
misty veil, or glass wall? (feelings of detachment from the outside world)
yes, often
0
0
sometimes
6
6
no
11
7
49. do you feel more surely or comfortable, when communicating with other people
indirectly? (telephone, electronic media, such as internet - chat, ICQ, Skype, e-mail, or
you like to film people on camera)
yes, often
4
0
sometimes
5
5
no
8
8
50. are you satisfied with the usual amout of energy, you have?
yes
10
7
partly
1
6
no
6
0
51. do you experience moments, when you can behave spontaneously and playfully like
child?
yes, often
sometimes
no
8
9
0
8
4
1
52. do you think you are sensuous?
yes
7
8
partly
10
5
no
0
0
53. have you ever done something with your body, which invoked guilt feelings in you?
yes, often
1
1
sometimes
8
8
no
8
4
54. if your parents or friends made some remarks in your childhood regarding your
body, they were rather:
positive
8
4
negative
2
2
neutral/I don´t remember
7
7
55. if your parents, friends, partner or people you meet, make some remarks in present
days regarding your body, they are rather:
positive
9
9
negative
0
0
neutral
8
4
56. did your parents (or parent and his partner) in your childhood express
spontaneously their relationship in you presence? (kissing, holding hands etc.)
yes, often
6
4
sometimes
9
7
no
2
2