Have you ever used Benzodiazepines for Non-Medical purpose? *

Yes

No

Have you ever intentionally used a higher dose than what was prescribed for you? *

Yes

No

Have you spent a substantial amount of time obtaining Benzodiazepines? *

Yes

I'm not sure how long I've been using it

No

Have you ever felt guilt or remorse about your Benzodiazepine use? *

Yes

No

How often do you use Benzos? (Xanax, Valium, Klonopin, etc.) *

Constantly

Every day or every other day

Once a week

Only when I am prescribed

Have you ever encountered legal issues because of you Benzo misuse? *

Yes

No

Have you suffered to maintain work, social, or familial responsibilities due to your Benzo misuse? *

Yes

No

Have you developed a tolerance to Benzos, meaning you need to take an increased amount over a short period of time for the desired effects? *

Yes

No

Have you experienced withdrawal signs and symptoms, or taken Benzos to avoid a withdrawal? *

Yes

No

Have you developed financial issues due to your Benzo misuse? *

Yes

No