Menopause Questionnaire
1. Email
example@example.com
2. Age
Enter your answer
3. Gender
Male
Female
Non-binary
Transgender
Prefer not to say
4. What Community do you identify with?
White / Caucasian
Black / African-Caribbean
Asian / South Asian
Mixed Ethnicity
Indigenous
Other
5. What is your Socio-Economic Status?
Low Income
Middle Income
High Income
6. Who would you be most likely to discuss your menopause symptoms/experiences with?
*
7. At what age did you begin to experience Menopause symptoms?
Under 40 (Early onset Menopause)
Under 40 (Medical Reasons)
40-45
46-50
Over 50
Not Sure
8. How would you rate the impact of Menopause on your Mental Health?
No Impact
Low Impact
Medium Impact
Significant Impact
High Impact
9. Which Mental Health Symptoms have you experienced due to Menopause? (Select all that apply)
Anxiety
Depression
Mood Swings
Irritability
Brain Fog
Insomnia or Sleep Disturbances
Other
10. Have you sought professional help (eg Counselling, therapy, or medical consultation) for Mental Health concerns related to Menopause?
Yes
No
I am considering it
11. Where did you go for help and support?
GP
Nurse
Hospital
Friends / Family
Community & Voluntary Groups
Other
12. Please explain why you went to this person / group for help and support?
*
13. If you received support, how would you rate the effectiveness of the care or treatment you received?
Very Effective
Good
Average
Poor
Fair
I have not sought support
14. How has menopause affected your ability to manage daily tasks or responsibilities?
No Impact
Slight Impact
Moderate Impact
Severe Impact
15a. What kind of support would you like to see for woman experiencing menopause related mental health challenges (Please rank from most important to least important)
15b. If you said Other for question 15a please specify.
16. Please feel free to share any additional thoughts or experiences on your experience with Menopause.
17. Which Constituency do you live in?
Please Select
East Derry
North Antrim
East Antrim
South Antrim
Belfast North
Belfast East
Belfast South
Belfast West
Strangford
South Down
North Down
Lagan Valley
Newry & Armagh
Upper Bann
Mid Ulster
Fermanagh & South Tyrone
West Tyrone
Foyle
As part of AWARE NI's commitment to maintaining your privacy and in compliance with the General Data Protection Regulation (GDPR), we want to inform you that the personal information collected in this survey will be used solely for internal purposes. Your data will be securely stored and will only be accessible to authorised personnel involved in survey analysis. We assure you that your information will not be shared with any third parties without your explicit consent. By participating in this survey, you consent to the processing of your personal data for the stated purposes.
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