Benzodiazepine Survey Two - Withdrawal Completed
Answers marked with a * are required.
1.
Benzodiazepine Survey Two - Withdrawal completed
The purpose of this survey is to collect statistical information from people who have completed their withdrawal from benzodiazepines or Z-drugs. Please complete this survey if you have completed your withdrawal in the last 12 months but are not yet recovered.
1.
What benzodiazepines or Z-drugs were you taking at the time you decided to withdraw?
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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?
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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?
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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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