The following questionnaire is for personal information only and is not meant to be a professional evaluation. As with many research questionnaires, this questionnaire may not be normed for online participants. Please take this into account when you receive the results. However, as more people complete these questionnaires the results will become more accurate. You may be asked after you complete the questionnaire to submit it for research purposes which will improve the accuracy of results.

This questionnaire determines how sensitive you are to rejection due to your appearance.

Each of the items below describes different scenarios that people might find themselves in. Please imagine yourself in each situation and circle the number that best indicates how you would feel.

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Situation 1: You are leaving your house to go on a first date when you notice a blemish on your face.

How concerned or anxious would you be that your date might be less attracted to you because of the way you looked?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect that the person would find me less attractive.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 2:  You are trying on clothes at a department store and notice that you are a few pounds heavier than last week.

How concerned or anxious would you be that others might be less attracted to you because of your physical appearance?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect that others would find me less attractive.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 3: You are at a party and are shorter than everyone there.

How concerned or anxious would you be that others would not be attracted to you because of the way you looked?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect that others would not be attracted to me because of the way I looked.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 4: You post a photo of yourself on an internet dating service.

How concerned or anxious would you be that people might not contact you because of the way you looked? (how physically attractive/unattractive you looked).

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would not expect people to contact me because of the way I looked.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 5: Your new boyfriend/girlfriend bought you a gym membership for your birthday.

How concerned or anxious would you be that you were bought this gift because of the way your body looked?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect that my significant other had given me this gift because of the way my body looked

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 6:During dinner at a restaurant, you notice your date looking at an attractive person across the room.

How concerned or anxious would you be that your date would be less interested in you because of the way you looked?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect that my date would be less interested in me because of the way I looked.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 7: You are waiting in line at a club and others in line behind you are being let in before you.

How concerned or anxious would you be that you were not let in because of your physical appearance?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would not expect to be let into the club because of my physical appearance.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 8: You met someone at a coffee shop and gave them your phone number. Three days have passed and you still have not heard anything.

How concerned or anxious would you be that they did not call you because of your physical appearance?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect that he/she would not call me because of the way I looked.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 9: Your boyfriend/girlfriend of 3 months is considering breaking up with you.

How concerned or anxious would you be that he/she might end the relationship because of the way you looked?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect that my boyfriend/girlfriend would break up with me because of the way I looked.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 10: You are at a dance club and all of your friends have been asked to dance except for you.

How concerned or anxious would you be that no one wanted to dance with you because of the way you looked?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect that no one would want to dance with me because of the way I looked.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 11:  You are set up on a blind date. The date goes well and you like the person, but he/she has not called you for several days.

How concerned or anxious would you be that your date did not call you because of the way you looked?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect that my date would not call me because of the way I looked.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 12: You are taking dance lessons that involve dancing with partners. When the instructor tells everyone to find a partner, no one chooses you.

How concerned or anxious would you be that you were not chosen to dance because of the way you looked?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect to not be chosen to dance because of the way I looked.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 13: Your significant other makes a comment about your weight.

How concerned or anxious would you be that your significant other might be less attracted to you because of the way you looked?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect my significant other to be less attracted to me because of the way I looked.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 14:Your hair is looking thin lately.

How concerned or anxious would you be that others might be less attracted to you because of your physical appearance?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect that others would find me less attractive.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

Situation 15:You look at yourself in the mirror and notice that your gut is getting larger.

How concerned or anxious would you be that others might be less attracted to you because of your physical appearance?

Very Unconcerned___________________________Very Concerned

  1          2          3          4          5         6

I would expect that others would find me less attractive.

Very Unlikely____________________________________Very Likely

  1         2          3          4          5         6

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