Note: copy this questionnaire and send your answers by e-mail to firstname.lastname@example.org
Other languages spoken
Occupation(s) in the past
Name of benzo prescribed
When was it first prescribed?
What warnings were given?
By whom was your benzo prescribed (eg. physician or psychiatrist)?
For what reason/symptoms?
With what medical/psychiatric diagnosis?
Initial dosage of the benzo
Duration period of initial prescription
Effects experienced during period of initial prescription
Number of weeks, months or years on the drug
Reason for any dose increase
Name of any other prescription drugs being taken
Name of any other prescription drugs taken in the past
Reasons or diagnoses given for prescription of these other medications
Short term effects of taking the benzo (negative and/or positive)
Long term effects (negative or positive)
Effects of any other drugs being taken (short and long term)
Signs of benzo dependency (eg discontinuation symptoms, need for dose increases)
How long did it take for symptoms of dependency to arise?
Short term symptoms of dependency, physical or psychological
Longer term symptoms of dependency, physical or psychological
Were any negative effects or dependency symptoms reported to the prescriber?
What was the response?
What help or advice was received for negative effects and/or dependency symptoms
Was any other diagnosis given or any other drugs prescribed for negative effects
Was advice given regarding methods of tapering?
Was the Ashton Manual recommended as a guide to tapering?
If the benzo being taken is not diazepam was it advised to first switch from the current benzo to an equivalent dose of diazepam?
What attempts were made to come off the drug (eg tapering, detox clinics, cold turkey)?
What advice or support was given by medical professionals during tapering?
What support was given by friends, family or though on-line support groups
If tapering was tried, at what rate of dose reduction per week or month?
Experience of tapering, rapid detox or cold turkey discontinuation?
How easily available and affordable are repeat prescriptions?
Has there been any need to obtain the benzo on the black market or through on-line pharmacies?
Any experiences of emergency hospitalisation?
Any experiences of psychiatric hospitalisation?
Current state of mental and physical health
Current or recent symptoms of dependency
Most continuous or regular symptoms
Any history of recreational drug use
History and level of alcohol use
Other health problems (neurological, gastrointestinal, respiratory, liver related etc.)
History of any acute or chronic illnesses suffered before taking benzos?
Degree of urgency of help requested (1-10)
Any other information