Q01
Long Text
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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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
27 questions · ~4 min
Q02
Multiple Choice
Which of the following best describes your current menopause status?
Q03
Long Text
How familiar are you with menopause care options available in your area?
Q04
Multiple Choice
Which of the following symptoms have you experienced in the last 4 weeks? Select all that apply.
Q05
Long Text
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
Multiple Choice
What makes it hard to get the menopause support you want? Select all that apply.
Q07
Long Text
Overall, how satisfied are you with the menopause-related care and support you currently have access to?
Q08
AI Interview
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
Long Text
Finally, a few questions about you to help us understand different perspectives. Your responses are confidential.
Q10
Long Text
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
Long Text
Overall, how bothersome have your menopause-related symptoms been in the last 4 weeks?
Q12
Long Text
How would you rate your most recent care provider's knowledge of menopause?
Q13
Long Text
Rank the following sources from most to least preferred for getting menopause information.
Q14
Long Text
How likely are you to recommend your current menopause care provider or service to a friend or family member experiencing menopause?
Q15
Long Text
What is your age?
Q16
Multiple Choice
In the last 12 months, which types of support have you used for menopause symptoms? Select all that apply.
Q17
Long Text
How well did you feel heard and understood during your most recent menopause-related appointment?
Q18
Long Text
Rank the following service features from most to least important to you when choosing menopause care.
Q19
Multiple Choice
How do you describe your gender?
Q20
Long Text
How clear was the care plan or next steps you received after your most recent menopause-related visit?
Q21
Long Text
What is your preferred appointment format for menopause care?
Q22
Multiple Choice
What sex were you assigned at birth?
Q23
Long Text
Approximately how long did you wait from first seeking help to your first menopause-related appointment?
Q24
Long Text
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?
Q25
Long Text
Where do you currently live?
Q26
Multiple Choice
What is the highest level of education you have completed?
Q27
Multiple Choice
What is your current employment status?
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.