Benzodiazepine Survey One - Getting Ready to Withdraw or Currently Withdrawing

Answers marked with a * are required.

1. Benzodiazepine Survey One - Getting Ready to Withdraw or Currently Withdrawing

The purpose of this survey is to collect statistical information from people who are intending to withdraw from benzodiazepines or Z-drugs. Please complete this survey if you are about to start withdrawing from these drugs or if you are currently in the process of withdrawing but have not yet completed the process.

1. What benzodiazepines or Z-drugs were you taking at the time you decided to withdraw? *

alprazolam (Xanax)

bromazepam (Lexotan, Lexomil)

chlordiazepoxide (Librium, Nova-Pam)

clonazepam (Klonopin, Rivotril)

clorazepate (Tranxene)

diazepam (Valium, D-Pam, Pro-Pam)

estazolam (ProSom)

flunitrazepam (Rohypnol)

flurazepam (Dalmane)

halazepam (Paxipam)

ketazolam (Anxon)

loprazolam (Dormonoct)

lorazepam (Ativan)

lormetazepam (Noctamid)

medazepam (Nobrium)

midazolam, (Versed, Hypnovel, Dormicum)

nitrazepam (Mogadon, Insoma, Nitrados)

prazepam (Centrax)

quazepam (Doral)

temazepam (Restoril, Euhypnos, Normison, Sompam)

triazolam (Halcion, Hypam, Tricam)

Zaleplon (Sonata)

Zolpidem (Ambien, Stilnoct, Stilnox)

Zopiclone (Zimovane, Imovane)

Eszopiclone (Lunesta)

Other (Please Specify)

2. How long had you been taking benzodiazepines or Z-drugs at the time you decided to withdraw? *

Under a month

1- 3 months

3 - 6 months

6 - 9 months

9 - 12 months

1 - 2 years

2 - 3 years

3 - 4 years

4 - 5 years

5 -10 years

10 -15 years

15 - 20 years

over 20 years

3. If you were only taking one benzodiazepine or Z-drug at the time you decided to withdraw, enter the number of milligrams per day you were taking.

4. If you were taking more than one benzodiazepine or Z-drug at the time of deciding to withdraw, enter the name of each of the drugs that you were taking, followed by the number of milligrams you were taking, e.g. Valium 30, Klonopin 2.

5. Why were you prescribed benzodiazepines or Z-drugs? *

Anxiolytic (tending to reduce anxiety/produce relaxation)

Hypnotic (tending to make you sleepy)

Anti-seizure (tending to reduce the probability of having seizures and convulsions)

Muscle relaxant (tending to reduce muscle tension and associated pain)

Amnesic (tending to disrupt both long and short term memory)

Other (Please Specify)


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