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Menopause Care Survey Template: Needs & Preferences

Use this menopause survey template to capture patient needs, care gaps, and preferred support across symptoms and resources. 8–12 minutes; start now.

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AI-Powered Questions

Intelligent follow-up questions based on responses

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Detailed Reports

Comprehensive insights and recommendations

Sample Survey Items

Q1
multiple choice
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
Q2
opinion scale
How familiar are you with menopause care options available in your area?
Q3
rating
Overall, how bothersome have your menopause-related symptoms been in the last 4 weeks?
Q4
multiple choice
Which 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
Q5
multiple choice
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/service
  • Alternative or complementary practitioner (e.g., acupuncturist, naturopath)
  • Self-care only (over-the-counter, lifestyle)
  • I have not sought care for menopause symptoms
Q6
matrix
Thinking about your most recent menopause-related care, how would you rate each aspect? If you have not received care, you may skip this item.
Q7
numeric
About how many days did you wait from first seeking help to your first appointment? Enter a whole number of days.
Q8
multiple choice
Attention check: To confirm attention, please select "Agree."
  • Strongly disagree
  • Disagree
  • Neutral
  • Agree
  • Strongly agree
Q9
multiple choice
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/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
Q10
long text
Please describe any other barriers or details about getting help (optional).
Max 600 chars
Q11
ranking
Rank the most helpful places you’d like to get menopause information.
Q12
constant sum
Allocate 100 points to show which service features matter most to you.
Q13
dropdown
If you could choose, what’s your preferred appointment format for menopause care?
Q14
numeric
What is the maximum monthly amount you’d be willing to pay out-of-pocket for an effective menopause support program (if not covered)? Enter a whole number in your local currency.
Q15
dropdown
What is your age?
Q16
multiple choice
How do you describe your gender?
  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q17
multiple choice
What sex were you assigned at birth?
  • Female
  • Male
  • Intersex
  • Prefer not to say
Q18
dropdown
Where do you currently live?
Q19
multiple choice
What is the highest level of education you have completed?
  • High school or less
  • Some college or vocational
  • Bachelor’s degree
  • Postgraduate (master’s/doctorate)
  • Prefer not to say
Q20
multiple choice
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
Q21
long text
Anything else you wish existed to better support menopause care?
Max 600 chars
Q22
ai interview
AI Interview: 2 Follow-up Questions on menopause care needs and preferences
AI Interview
Q23
chat message
Thank you for participating—your input will help improve menopause care.

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Menopause Care Survey Template: Needs & Preferences - Survey Template | QuestionPunk