The Phoenix Rising Klonopin and Benzodiazepine Survey

The 'Other Benzodiazpine' Section (Alprazolam (Xanax, Helex, etc), Diazepam (Antenex, Valium, etc.), Lorezepam (Atvian, Temesta, etc.), Temezepam (Restoril, etc.), Triazolam (Halcion). (Click here for a complete list )

Please complete this section if you have taken a benzodiazepine other than Klonopin. (The third page of the survey allows you to review one more benzodiazepine)

This benzodiazepine is

Alprazolam (Xanax, Helex, etc)
Diazepam (Antenex, Valium, etc.)
Lorezepam (Atvian, Temesta, etc.)
Temezepam (Restoril, etc.)
Triazolam (Halcion)
Other
Other
Other

My doctor prescribed this benzodiazepine for me as a

Sleep aid
Calming agent
Other

The maximum dose of this benzodiazepine that I took was

.25 mgs/day or less
.5 mgs/day
1 mg/day
2 mgs/day
3 mgs/day
4 mgs/day
> 4 mgs/day

I took or have taken this benzodiazepine for

<1 month
<6 months
6-12 months
1-2 years
2-5 years
> 5 years

I'm currently taking or was taking this benzodiazepine

daily
couple of times a week
less than a couple of times a week
intermittently

This benzodiazepine has been

very helpful for me
somewhat helpful for me
I have not noticed any changes
somewhat harmful for me
very harmful for me

Benzodiazepine Use - Tolerance, Withdrawal, Addiction

I have been diagnosed with or exhibited signs of

tolerance (I have had to up my dose in order to get the same effect)
addiction (I have felt a craving for more of the drug

While you were taking this benzodiazepine did you notice signs of 'tolerance withdrawal ? (Tolerance withdrawal occurs when you become tolerant to a medication and begin having 'withdrawal' symptoms without going off the medications -see the next two questions for symptoms of tolerance withdrawal).

'tolerance withdrawal'

yes
no
I don't know

Please check any psychological symptoms that you experienced after you began taking this benzodiazepine (These can be signs of 'tolerance withdrawal.)

anxiety (including panic attacks)
depression
insomnia
derealization/depersonalization (feelings of unreality/detachment from self)
obsessive negative thoughts (particularly of a violent and/or sexual nature)
rapid mood changes (including especially outbursts of anger or rage)
phobias (especially agoraphobia and fear of insanity)
dysphoria (loss of capacity to enjoy life; possibly a combination of depression, anxiety, and derealization/depersonalization)
impairment of cognitive functioning
suicidal thoughts
nightmares
hallucinations
psychosis

Please check any new physical symptoms which you experienced after you began taking this benzodiazepine.

sensory hypersensitivity (to sounds, odors, touch, taste, light..)
headache
pain/stiffness
tingling, numbness
weakness
fatigue/flu-like symptoms
muscle twitches, jerks, tics, tremor
dizziness, lightheadedness, poor balance
tinnitus (ringing in ears)
double vision
nausea, vomiting ,constipation, bloating, etc.
flushing, sweating, palpitations
urinary difficulties
dry mouth
rashes

If you have stopped this benzodiazepine please answer the following question...When I stopped taking this drug, I

Had no negative effects
Some minor side effects
Some moderate side effects
Severe side effects
Very severe side effects

If you stopped taking this benzodiazepine please tell us how you did it

I withdrew from it under my doctors care
I withdrew from it using a specialist
I withdrew from it using a detox clinic

If you stopped using this benzodiazepine please answer the following question..... "When I stopped using this drug I did.... " (Please check all that apply.)

not use other drugs to help me withdraw from drug
use other drugs to help me withdraw from the drug. Please tell us which drugs you used.

If you stopped taking this benzodiazepine please answer this question. How long did it take after you stopped using it for any withdrawal symptoms to disappear?

No time...I didn't have any withdrawl symptoms
About 1 week
1-2 weeks
2-4 weeks
1-2 months
2 - 6 months
>6 months. . Please let us how about how long it took

The Phoenix Rising Klonopin and Benzodiazepine Survey

The 'Other Benzodiazpine' Section (Alprazolam (Xanax, Helex, etc), Diazepam (Antenex, Valium, etc.), Lorezepam (Atvian, Temesta, etc.), Temezepam (Restoril, etc.), Triazolam (Halcion). (Click here for a complete list )

Please complete this section if you have taken a benzodiazepine other than Klonopin. (The third page of the survey allows you to review one more benzodiazepine)

This benzodiazepine is

My doctor prescribed this benzodiazepine for me as a

The maximum dose of this benzodiazepine that I took was

I took or have taken this benzodiazepine for

I'm currently taking or was taking this benzodiazepine

This benzodiazepine has been

Benzodiazepine Use - Tolerance, Withdrawal, Addiction

I have been diagnosed with or exhibited signs of

While you were taking this benzodiazepine did you notice signs of 'tolerance withdrawal ? (Tolerance withdrawal occurs when you become tolerant to a medication and begin having 'withdrawal' symptoms without going off the medications -see the next two questions for symptoms of tolerance withdrawal).

Please check any psychological symptoms that you experienced after you began taking this benzodiazepine (These can be signs of 'tolerance withdrawal.)

Please check any new physical symptoms which you experienced after you began taking this benzodiazepine.

If you have stopped this benzodiazepine please answer the following question...When I stopped taking this drug, I

If you stopped taking this benzodiazepine please tell us how you did it

If you stopped using this benzodiazepine please answer the following question..... "When I stopped using this drug I did.... " (Please check all that apply.)

If you stopped taking this benzodiazepine please answer this question. How long did it take after you stopped using it for any withdrawal symptoms to disappear?

Please add any other comments here.

If you've taken another benzodiazepine please go to the third page of the survey.