| Question | Possible Responses |
| Do you experience ringing (or other noises) in your ears? | (Yes/No) |
| Do you experience dizziness? | (Yes/No) |
| How long have you been suffering from these symptoms? | 0 - 2 months |
| 3 months - 1 year | |
| More than 1 year | |
| As of today, please rate how bothersome the ringing (or other noises) in your ears is when it’s most bothersome? | Not bothersome 1 2 3 |
| Somewhat bothersome 4 5 6 7 | |
| Extremely bothersome 8 9 10 | |
| Not applicable | |
| As of today, please rate how bothersome the dizziness is when it’s most bothersome? | Not bothersome 1 2 3 |
| Somewhat bothersome 4 5 6 7 | |
| Extremely bothersome 8 9 10 | |
| Not applicable | |
| As of today, please describe what time(s) of day or night your symptoms are most bothersome? | Open text response |
| Except for this bottle, have you ever taken Lipo-Flavonoid® Plus before? | Yes |
| No | |
| If you took Lipo-Flavonoid® Plus in the past, were you satisfied with symptom relief? | Yes |
| No | |
| Never took before | |
| Is using a product that is #1 doctor recommended important to you? | Yes |
| No |