OMB Control No. 0910-0847
Expiration Date: 12/31/2022
Attachment C
Benzodiazepines
Please check all the brand names you recall using during the past 12 months. If you do not recall the brand name, just check the generic name.
Generic Names |
Brand Names |
Please check if you have used during 12 months prior to beginning treatment |
Alprazolam |
|
|
|
Xanax |
|
Chlordiazepoxide |
|
|
|
Librium |
|
Librax |
|
|
Clobazam |
|
|
|
Onfi |
|
Clonazepam |
|
|
|
Klonipin |
|
Clorazepate |
|
|
|
Tranxene |
|
Gen-Xene |
|
|
Diazepam |
|
|
|
Valium |
|
Estazolam |
|
|
|
Prosom |
|
Flurazepam |
|
|
|
Dalmane |
|
Lorazepam |
|
|
|
Ativan |
|
Midazolam |
|
|
|
Versed |
|
Oxazepam |
|
|
|
Serax |
|
Quazepam |
|
|
|
Doral |
|
Temazepam |
|
|
|
Restoril |
|
Triazolam |
|
|
|
Halcion |
|
First Name: _____________ Date/Time of Full Interview with MHA: ______________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Mark Herring |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |