すべてのテンプレート
Healthcare & Clinical

Menopause Care Needs & Preferences Assessment

A patient-facing needs assessment capturing menopause symptom burden, care access barriers, and service preferences to inform care model design and resource prioritization.

設問の例

テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。

全27問・約12分
Q01
メッセージ

Welcome to the Menopause Care Needs & Preferences Survey. This survey asks about your menopause-related symptoms, care experiences, and preferences for support. Your responses are confidential, will be reported only in aggregate, and will be used to improve menopause care services. Participation is voluntary and you may stop at any time. There are no right or wrong answers — we are interested in your honest opinions and experiences. Estimated time: 8–10 minutes.

Q02
選択式

Which of the following best describes your current menopause status?

  • Perimenopausal (periods changing, new symptoms)
  • In menopause (12 months without a period)
  • Postmenopausal
  • Not sure
  • Not experiencing menopause-related changes
  • Prefer not to say
Q03
オピニオンスケール

How familiar are you with menopause care options available in your area?

スケール: 1 – 7
最小:Not at all familiar最大:Extremely familiar
Q04
選択式

Which of the following symptoms have you experienced in the last 4 weeks? Select all that apply.

  • Hot flashes or night sweats
  • Sleep disruption or insomnia
  • Mood changes (e.g., anxiety, irritability)
  • Cognitive changes (e.g., brain fog, memory)
  • Vaginal dryness or discomfort
  • Low libido
  • Joint or muscle pain
  • Weight changes
  • Headaches or migraines
  • Other
  • None of the above
  • Prefer not to say
Q05
メッセージ

The next few questions ask about your most recent menopause-related care experience. If you have not received care, please select 'Not applicable' where available or skip ahead.

Q06
選択式

What makes it hard to get the menopause support you want? Select all that apply.

  • Unsure where to seek care
  • Hard to get appointments
  • Cost or insurance coverage
  • Limited local specialists
  • Past negative experiences
  • Stigma or discomfort discussing symptoms
  • Transportation or childcare challenges
  • Time constraints
  • Privacy concerns
  • Symptoms feel manageable without care
  • Other (please specify)
  • No barriers experienced
Q07
オピニオンスケール

Overall, how satisfied are you with the menopause-related care and support you currently have access to?

スケール: 1 – 7
最小:Very dissatisfied最大:Very satisfied
Q08
AIインタビュー

Based on your responses in this survey, please share any additional thoughts about your menopause care experience, unmet needs, or what you wish existed to better support you.

Q09
メッセージ

Finally, a few questions about you to help us understand different perspectives. Your responses are confidential.

Q10
メッセージ

Thank you for completing this survey. Your responses will be kept confidential and used to improve menopause care services. We appreciate your time and openness.

Q11
オピニオンスケール

Overall, how bothersome have your menopause-related symptoms been in the last 4 weeks?

スケール: 1 – 7
最小:Not at all bothersome最大:Extremely bothersome
Q12
オピニオンスケール

How would you rate your most recent care provider's knowledge of menopause?

スケール: 1 – 7
最小:Very poor最大:Excellent
Q13
ランク付け

Rank the following sources from most to least preferred for getting menopause information.

  1. Primary care provider or OB-GYN
  2. Pharmacist
  3. Specialist menopause clinic
  4. Trusted health websites
  5. Support groups or communities
  6. Mobile app or digital program
ドラッグして順位を付ける
Q14
オピニオンスケール

How likely are you to recommend your current menopause care provider or service to a friend or family member experiencing menopause?

スケール: 0 – 10
最小:Not at all likely最大:Extremely likely
Q15
プルダウン

What is your age?

  • 18–24
  • 25–34
  • 35–44
  • 45–54
  • 55–64
  • 65+
  • Prefer not to say
Q16
選択式

In the last 12 months, which types of support have you used for menopause symptoms? Select all that apply.

  • Primary care clinician / GP
  • OB-GYN / gynecology specialist
  • Endocrinologist
  • Nurse practitioner / physician assistant
  • Pharmacist guidance
  • Therapist / counselor
  • Support group (online or in-person)
  • Menopause-focused clinic or service
  • Alternative or complementary practitioner (e.g., acupuncturist, naturopath)
  • Self-care only (over-the-counter, lifestyle changes)
  • I have not sought care for menopause symptoms
  • Other (please specify)
  • Prefer not to say
Q17
オピニオンスケール

How well did you feel heard and understood during your most recent menopause-related appointment?

スケール: 1 – 7
最小:Not at all heard最大:Completely heard
Q18
ランク付け

Rank the following service features from most to least important to you when choosing menopause care.

  1. Clinicians with menopause expertise
  2. Short wait times
  3. Clear, personalized care plan
  4. Insurance coverage and cost transparency
  5. Follow-up and ongoing check-ins
  6. Option for virtual and in-person visits
  7. Culturally responsive and inclusive care
ドラッグして順位を付ける
Q19
選択式

How do you describe your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q20
オピニオンスケール

How clear was the care plan or next steps you received after your most recent menopause-related visit?

スケール: 1 – 7
最小:Not at all clear最大:Extremely clear
Q21
プルダウン

What is your preferred appointment format for menopause care?

  • In-person
  • Video visit
  • Phone
  • Chat or asynchronous messaging
  • No preference
Q22
選択式

What sex were you assigned at birth?

  • Female
  • Male
  • Intersex
  • Prefer not to say
Q23
プルダウン

Approximately how long did you wait from first seeking help to your first menopause-related appointment?

  • Less than 1 week
  • 1–2 weeks
  • 3–4 weeks
  • 1–2 months
  • 3–6 months
  • More than 6 months
  • I have not sought a menopause-related appointment
  • Don't remember
Q24
プルダウン

What is the most you would be willing to pay per month out-of-pocket for a menopause support program, if not covered by insurance?

  • $0 — I would only use a free program
  • $1–$25
  • $26–$50
  • $51–$100
  • $101–$150
  • $151–$200
  • More than $200
  • Not sure
Q25
プルダウン

Where do you currently live?

  • United States
  • Canada
  • United Kingdom
  • European Union
  • Australia / New Zealand
  • Other
  • Prefer not to say
Q26
選択式

What is the highest level of education you have completed?

  • High school or less
  • Some college or vocational
  • Bachelor's degree
  • Postgraduate (master's or doctorate)
  • Prefer not to say
Q27
選択式

What is your current employment status?

  • Full-time
  • Part-time
  • Self-employed
  • Unemployed and looking for work
  • Homemaker / caregiver
  • Student
  • Retired
  • Unable to work
  • Prefer not to say

含まれる機能

  • AIによる深掘り

    自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。

  • 注意確認設問

    急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。

  • AIが作成する設問文

    文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。

  • 自動レポート

    回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。

他ツールとの比較

ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。

このテンプレートを選ぶ理由

  • Includes an AI follow-up interview that adapts to each respondent's own symptom and care-experience answers, going beyond fixed-choice questions to surface unstructured 'additional thoughts' patients wouldn't otherwise volunteer
  • Covers the full care-journey arc in one instrument: symptom burden and bothersomeness, most recent provider experience (knowledge, being heard, clarity of care plan), wait times, cost willingness-to-pay, and ranked service/channel preferences
  • Uses ranking questions to force-prioritize preferred information sources and service features, giving care-model designers clear trade-off data rather than just satisfaction scores
  • Pairs quantitative opinion-scale and multiple-choice items with transparent, auditable AI prompts and an automated report, so teams can validate exactly how the qualitative follow-up was generated

Jotform

600+ Healthcare Assessment Forms

This is a broad category hub linking to hundreds of generic healthcare assessment forms, not a purpose-built menopause needs-assessment template. It's useful as a starting point for form building and customization but requires assembling the menopause-specific question set yourself. Good for teams who want drag-and-drop form design over a ready-to-field survey.

優れている点

  • Large library of pre-built healthcare form templates to adapt
  • Drag-and-drop form builder for quick customization
  • Broad healthcare category coverage beyond menopause

物足りない点

  • No menopause-specific needs assessment content out of the box
  • Static form fields only — no adaptive AI follow-up probing on symptom or care-experience answers
  • No built-in quality scoring or automated qualitative report generation

Typeform

Online Community Needs Assessment Survey Template

A general-purpose community needs assessment template with Typeform's conversational form style, not tailored to menopause symptoms, care barriers, or clinical experience. It can be manually customized but starts from generic community-needs questions rather than menopause-specific content. Fielding-ready for broad needs assessments, but would need substantial rework for this use case.

優れている点

  • Polished, conversational question flow that feels less clinical
  • Flexible template structure adaptable to different needs-assessment contexts
  • Established brand for consumer-friendly survey design

物足りない点

  • No menopause-specific symptom, care-access, or provider-experience questions
  • No adaptive AI interviewing — follow-up logic is limited to fixed branching, not open-ended probing
  • No automated per-response quality scoring or transparent AI prompt documentation

QuestionPro

Healthcare Opinion Survey Template

A generic healthcare opinion survey template covering general satisfaction and opinion questions, not specific to menopause care needs, symptom burden, or service design preferences. It's ready to field for broad healthcare opinion capture but lacks the condition-specific depth and journey-stage structure of a menopause needs assessment. Suitable as a general satisfaction pulse rather than a service-design planning tool.

優れている点

  • Ready-to-field generic healthcare opinion survey
  • Established survey platform with reporting and analytics tooling
  • Broad applicability across healthcare topics

物足りない点

  • No menopause-specific content on symptoms, care barriers, or service preferences
  • Fixed-question format with no adaptive AI follow-up interview or voice AI option
  • No transparent prompt methodology or automated qualitative synthesis report

よくあるご質問

「Menopause Care Needs & Preferences Assessment」テンプレートにはどのような設問が含まれていますか?

すぐに使える設問が27問含まれており、最初の設問は次のとおりです:「Welcome to the Menopause Care Needs & Preferences Survey. This survey asks about your menopause-related symptoms, care…」・「Which of the following best describes your current menopause status?」・「How familiar are you with menopause care options available in your area?」。すべての設問は上でプレビューでき、自由に編集できます。

このアンケートの回答にはどのくらい時間がかかりますか?

回答者は通常、27問を約12分で回答し終えます。

テンプレートは編集できますか?

はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。

このテンプレートは無料で使えますか?

はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。

公開の準備はできましたか?

このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。

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