Are You At Risk For Developing Tinnitus? Please check the boxes below if your answer to the questions or statement is YES* 1. Do you work or spend time in a noisy environment, such as factory setting or airport? 2. Do you often use power tools or equipment? 3. Do you use firearms? 4. Have you attended numerous loud social events, such as music concerts, sports events or clubs? 5. Does anyone in your family experience tinnitus? 6. Have you used medications such as Aspirin, Acetaminophen, Advil, Alka-seltzer in high doses over a long period of time? 7. Have you been exposed to chemotherapeutic medications? 8. Have you ever used ototoxic antibiotics? 9. Do you have excessive stress levels? 10. Have you had any major head trauma or concussion? 11. Do you grind your teeth? 12. Do you experience clicking or popping sounds when chewing hard food? 13. Have you been diagnosed with any of the following conditions: High Blood Pressure | Thyroid Disorder | Lyme Disease | Autoimmune Disorder | Cardiovascular Problems 14. Do you smoke? 15. Do you drink alcoholic beverages more than twice a week? 16. Do you have a hearing loss? Name* First Last Email* Phone
