Peri/Menopausal Women's Health Survey - Anonymous from the Institute of Women's Futures)
1.
What is your age?
35-45
46-55
56-65
66-75
76-80
80+
2.
What is your ethnicity and/or racial background?
American Indian or Alaska Native
Asian or Asian American
South Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Another race
Prefer not to answer
3.
What is your annual household income?
Under $15,000
Between $15,000 and $29,999
Between $30,000 and $49,999
Between $50,000 and $74,999
Between $75,000 and $99,999
Between $100,000 and $150,000
Over $150,000
Over $250,000
4.
What level of insurance do you currently hold?
Standard coverage from my employer
Excellent coverage from my employer
Standard coverage through a spouse or family member
Excellent coverage through a spouse or family member
Medicaid/Medicare/ Tricare (or any government insurance)
No coverage
5.
What are your current perimenopause/menopause symptoms? (Check all that apply)
Hot flashes
Night sweats
Brain fog
Mood swings
Vaginal dryness
Recurring UTIs
Low libido/ low sex drive
Memory loss
Urinary urgency
Difficulty sleeping and/or disturbed sleep
Migraines
Painful breasts
Irregular periods
Heavy bleeding
Weight gain
Anxiety
Depression
Rising cholesterol
Other (please specify)
6.
How severe are your symptoms on a daily basis?
Extremely severe
Moderately severe
Generally manageable
Easily manageable
Other (please specify)
7.
Are you fully menopausal (have you gone one year or more without a period)?
Yes, I've gone more than 1 year without a period
No, I still have semi-regular or regular periods
8.
If you’re fully menopausal, was it surgical or natural?
Surgical, the result of a full or partial hysterectomy
Natural, no full or partial hysterectomy
9.
How important are these qualities in your perimenopausal/menopausal healthcare provider:
Urgent
Very important
Somewhat important
Not very important
Supportive, kind, good listener, trustworthy
Urgent
Very important
Somewhat important
Not very important
Takes my insurance
Urgent
Very important
Somewhat important
Not very important
Provides evidence-based treatment options
Urgent
Very important
Somewhat important
Not very important
Open to other treatment options that I choose
Urgent
Very important
Somewhat important
Not very important
Can work within my budget
Urgent
Very important
Somewhat important
Not very important
Other (please specify)
10.
Would you be willing to pay cash for the menopausal care you feel you need?
Yes
No
Other (please specify)
11.
Are there any other chronic conditions (mental and/or physical) that you deal with on a daily basis?
Mental Health/Wellness/Acuity
Immunodeficiencies
Diabetes
Heart Disease
Stroke
Other (please specify)
12.
What concerns you most about aging and menopause?
Symptoms Persisting (hot flashes, night sweats, insomnia, etc.)
Risk of Dementia/Alzheimers
Loneliness/Lack of Community
Housing/Financial Insecurity
Chronic Illness/Decline
Other (please specify)