Benzodiazepine Survey Eight - Decided not to Withdraw
Answers marked with a * are required.
1.
Benzodiazepine Survey Eight - Decided not to Withdraw
The purpose of this survey is to collect statistical information from people who have decided not to withdraw from benzodiazepines or Z-drugs in the immediate future. Please complete this survey if you fall into this group.
1.
What benzodiazepines or Z-drugs are you currently taking?
*
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 have you been taking benzodiazepines or Z-drugs?
*
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 are only taking one benzodiazepine or Z-drug, please enter the number of milligrams per day you are taking.
4.
If you are taking more than one benzodiazepine or Z-drug at this time, enter the name of each drug that you are taking, followed by the number of milligrams you are 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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