Experience Box Quiz

1
Name* This field is required.Nice to meet you!
First Name
Last Name
2
Email* This field is required.We'll need this to deliver your personalized product recommendation and start your home trial. BLUEMOTH uses the contact information you provide to contact you about our products and services. You may unsubscribe from these communications at any time. For information on how to unsubscribe, as well as our privacy practices, please review our Privacy Policy.
example@example.com
3
Phone Number* This field is required.If you provide your phone number you consent to receive marketing text messages at the phone number provided. Consent is not a condition to purchase. Msg & data rates may apply. Msg frequency varies. Reply HELP for help and STOP to cancel.For information on how to unsubscribe, as well as our privacy practices, please review our Privacy Policy.
Please enter a valid phone number.
4
What's your age range?* This field is required.
18-35
36-45
46-60
61-75
75+
5
Do you have hearing loss?* This field is required.
No
Maybe
Yes
6
When was your last hearing test with a healthcare professional?* This field is required.
I had a hearing test within the last year.
I had a hearing test within the last 3 years.
I've had my hearing tested before, but it was more than 3 years ago
I've never had a hearing test
7
Do you own hearing aids?* This field is required.
I own hearing aids now, and I like them.
I own hearing aids now, and I don't like them.
I have owned hearing aids before, but I don't own any right now.
I have never owned hearing aids
8
How soon would you like to address your hearing concerns?* This field is required.
Now
In the next 6 months
In the next year
Not sure
9
Do you experience tinnitus?* This field is required.
No
Maybe
Yes
10
On a scale from 1-10 how loud is your tinnitus?* This field is required.
11
On a scale from 1-10 how bothersome is your tinnitus?* This field is required.
12
Does your tinnitus make you feel frustrated, angry, or unhappy?* This field is required.
YESNO
13
Does your tinnitus make it difficult for you to sleep?* This field is required.
YESNO
14
I enjoy an active lifestyle with lots of physical activity, sports, or time spent outdoors.* This field is required.
Disagree
Neutral
Agree
15
I enjoy attending concerts, sporting events, or social outings with large groups.* This field is required.
Disagree
Neutral
Agree
16
I enjoy streaming TV/movies, music, podcasts, or gaming.* This field is required.
Disagree
Neutral
Agree
17
I travel often, and find myself frequently on-the go..* This field is required.
Disagree
Neutral
Agree
18
Sound clarity comes first for me.* This field is required.I don't want to miss a single detail in my sound environment, even if it means sacrificing a little bit of comfort.
Disagree
Neutral
Agree
19
I find it challenging to hear in background noise.* This field is required.When I'm in a noisy environment, I have trouble understanding conversations.
Disagree
Neutral
Agree
20
Is there anything else you want to share about your hearing story?We're all ears!
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: