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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.

Sample questions

A preview of what’s in the template. Every question is editable before you launch.

27 questions · ~12 min
Q01
Message

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
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
Q03
Opinion Scale

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

Scale: 17
Min:Not at all familiarMax:Extremely familiar
Q04
Multiple Choice

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
Message

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.

  • 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
Opinion Scale

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

Scale: 17
Min:Very dissatisfiedMax:Very satisfied
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
Message

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

Q10
Message

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
Opinion Scale

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

Scale: 17
Min:Not at all bothersomeMax:Extremely bothersome
Q12
Opinion Scale

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

Scale: 17
Min:Very poorMax:Excellent
Q13
Ranking

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
Drag to rank
Q14
Opinion Scale

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

Scale: 010
Min:Not at all likelyMax:Extremely likely
Q15
Dropdown

What is your age?

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

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

Scale: 17
Min:Not at all heardMax:Completely heard
Q18
Ranking

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
Drag to rank
Q19
Multiple Choice

How do you describe your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q20
Opinion Scale

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

Scale: 17
Min:Not at all clearMax:Extremely clear
Q21
Dropdown

What is your preferred appointment format for menopause care?

  • In-person
  • Video visit
  • Phone
  • Chat or asynchronous messaging
  • No preference
Q22
Multiple Choice

What sex were you assigned at birth?

  • Female
  • Male
  • Intersex
  • Prefer not to say
Q23
Dropdown

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
Dropdown

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
Dropdown

Where do you currently live?

  • United States
  • Canada
  • United Kingdom
  • European Union
  • Australia / New Zealand
  • Other
  • Prefer not to say
Q26
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 or doctorate)
  • Prefer not to say
Q27
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

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.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • 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.

What it does well

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

Where it falls short

  • 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.

What it does well

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

Where it falls short

  • 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.

What it does well

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

Where it falls short

  • 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

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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