Menopause Survey

page 1

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1. What year were you born?

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2. Ethnic/cultural background (may select multiple):

White

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Indigenous

Another race

Other (please specify)

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3. What type of setting do you live in?

Urban

Suburban

Rural

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4. How tall are you?

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5. How much do you weigh (in pounds)?

600

Clear

i We adjusted the number you entered based on the slider’s scale.

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6. How old were you when you had your first period?

Clear

i We adjusted the number you entered based on the slider’s scale.

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7. Was/is your monthly period predictable within a couple days?

Yes

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8. Did/do you experience premenstrual syndrome (PMS)? For example, acne, mood swings, irritability, anxiety, etc.

Yes

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9. Did/does your monthly period impact your normal activities (e.g. not going to work, skipping plans with friends)?

Always

Usually

Sometimes

Rarely

Never

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10. Was/is your period:

Heavy

Medium

Light

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11. Have you ever been diagnosed with a menstrual disorder?

Yes

Menopause Survey

page 1

Question Title

* 1. What year were you born?

Question Title

* 2. Ethnic/cultural background (may select multiple):

Question Title

* 3. What type of setting do you live in?

Question Title

* 4. How tall are you?

Question Title

* 5. How much do you weigh (in pounds)?

Question Title

* 6. How old were you when you had your first period?

Question Title

* 7. Was/is your monthly period predictable within a couple days?

Question Title

* 8. Did/do you experience premenstrual syndrome (PMS)? For example, acne, mood swings, irritability, anxiety, etc.

Question Title

* 9. Did/does your monthly period impact your normal activities (e.g. not going to work, skipping plans with friends)?

Question Title

* 10. Was/is your period:

Question Title

* 11. Have you ever been diagnosed with a menstrual disorder?

1. What year were you born?

2. Ethnic/cultural background (may select multiple):

3. What type of setting do you live in?

4. How tall are you?

5. How much do you weigh (in pounds)?

6. How old were you when you had your first period?

7. Was/is your monthly period predictable within a couple days?

8. Did/do you experience premenstrual syndrome (PMS)? For example, acne, mood swings, irritability, anxiety, etc.

9. Did/does your monthly period impact your normal activities (e.g. not going to work, skipping plans with friends)?

10. Was/is your period:

11. Have you ever been diagnosed with a menstrual disorder?