Project Dead Ringer Pre-Appointment Information
Please don't put down any information you're not comfortable with me having on my Google Drive. I have no plans to ever use any identifying information to do absolutely anything other than address your own individual tinnitus case. I am not a doctor, and will not be giving you medical advice as such nor will I be sharing your information for purposes outside of classifying types distinctions of tinnitus within the scope of this project. If you are not part of the Kickstarter study and have no reason to give me your home address, please leave it blank.
Last Name
First Name
Middle Initial
Phone Number
Mailing Address (if receiving headphones from us)
Email
Which of the following best describes your tinnitus?
ล้างสิ่งที่เลือก
Do you perceive your tinnitus in...
ล้างสิ่งที่เลือก
Please list any medications you are currently taking, prescription/over-the-counter or illicit, regularly that you feel comfortable sharing.
Please provide, if known, any possible causes for your tinnitus.
Have you been diagnosed with any medical conditions that might be relevant to your jaw, neck, central nervous system, or ear canal?
Please list your job/work site history in loud working environments.
Go to "https://www.szynalski.com/tone-generator/" and use that webpage's simple tool to try to hone in on the frequency of your tinnitus. Give us the value in Hz, the type of waveform (you can adjust it with a button on the bottom right), and how your tinnitus reacted to the tone generator. Please also tell us how your tinnitus differs from what you were able to construct with the tone generator.
ส่ง
ล้างแบบฟอร์ม
ห้ามส่งรหัสผ่านใน Google ฟอร์ม
เนื้อหานี้มิได้ถูกสร้างขึ้นหรือรับรองโดย Google รายงานการละเมิด - ข้อกำหนดในการให้บริการ - นโยบายความเป็นส่วนตัว
Google ฟอร์ม