Are you currently taking any of the following medications: Valium (diazepam), Xanax (alprazolam), Ativan (lorazepam), Librium (chlordiazepoxide), Klonopin (clonazepam), Tranxene (clorazepate), ProSom (estazolam), Serax (oxazepam), Dalmane (flurazepam), or Restoril (temazepam)? If yes, circle the name of the medication most commonly used.
Yes……………1
No…………….2
On average, how many days per week will you take one of these medications?
______________
How many months have you been taking these medications?
______________
What is the usual dose that you take?
_________ mg or pills—circle mg or pills
Are you currently taking any of the following medications: codeine-containing products such as Percocet, Percodan, Tylenol 3, or other medications such as Demerol (meperidine) or Darvon (propoxyphene)? If yes, circle the name of the medication most commonly used.
Yes………………….1
No…………………..2
On average, how many days per week will you take one of these medications?
__________________
How many months have you been taking these medications?
__________________
What is the usual dose that you take?
_________ mg or pills—circle mg or pills