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Step 1 of 9

Welcome to the ForgTin® Self-check Questionnaire!

We look forward to accompanying you on your first step towards a better quality of life. With our self-test, you can find out quickly and easily if you are a candidate for ForgTin.

Your results will be sent to the email provided. Please fill out the information below:

Name*

First Last

Email*

Phone*

Consent*

By submitting your self-test, you allow us to use and store your data to answer your questions quickly and reliably, as well as for placing future orders with Peaceful Ear.

We recognize that your data is private. It will not be used for marketing purposes or sold to any other parties.

How long have you had your ear ringing/buzzing symptoms?*

Enter the estimated year these issues started

How did your symptoms start?*

Immediately

Gradually

Have you had or do you have complaints (accidents, illnesses, poor posture, pain) in the areas of the knees, hips, spine, shoulders, neck, and/or head?*

Yes

I am not sure

The following exercises require a quiet, calm environment. Please pay attention to your symptoms and any changes in volume or frequency. These changes can be very subtle.

Do your symptoms change (very minimally for a short time) when:

you move your head far forward and then back again?

you slowly turn your head far to your right shoulder and then over to your left shoulder?

you slowly bend your head far forward and then far back?

you slowly tilt your head far toward your right shoulder and then toward your left shoulder?

If you slowly move your head far forward and then back again*

Yes

I am not sure

If you slowly turn your head far to your right shoulder and then over to your left shoulder*

Yes

I am not sure

If you slowly bend your head far forward and then far back*

Yes

I am not sure

If you slowly tilt your head far toward your right shoulder and then toward your left shoulder*

Yes

I am not sure

Have you had or do you have discomfort or pain in the area of the jaw, jaw joint or jaw muscles (illnesses, accidental injuries, tension, misalignment, teeth grinding, etc.)?*

Yes

I am not sure

The following exercises will again require a quiet, calm environment. Please pay attention to your symptoms and any changes in volume or frequency. These changes can be very subtle.

Do your symptoms change very minimally for a short time when:

You slowly move your lower jaw far forward and then back*

Yes

I am not sure

You move your upper and lower jaw crosswise apart to the left and right*

Yes

I am not sure

You open your mouth wide and then close it again*

Yes

I am not sure

You clench your teeth tightly and then release them*

Yes

I am not sure

Do your symptoms change, very minimally for a short time, when:

You or another person pulls your ears back, up, or down?*

Yes

I am not sure

You or another person presses or massages around the ears?*

Yes

I am not sure

Do you now, or did you ever, perceve a connection between stress, pressure, worry, anger, or other stress and your ear ringing/buzzing?*

Enhances my symptoms

Reduces my symptoms

Has no effect on my symptoms

Not sure

Thank you for completing the questionnaire!

Please click Submit to receive your results!

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Peaceful Ear is the exclusive distributor of ForgTin in the United States. It is our goal to bring relief to those who are suffering.

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contact@peacefulear.com