Benzo Detox Assessment

CLICK HERE for a printable version.

The benzo detox assessment questionnaire will help us fully understand your specific prescription medications and benzo addiction history. We will make sure your detox plan includes proper medication management for a healthy recovery.

Fill Out Our Benzo Detox Questionnaire Below:

YOUR NAME: ____________________________________________

ADDRESS: _____________________________________________

PHONE NUMBER: _______________________________________

EMAIL: ________________________________________________

FAX: __________________________________________________

Can you be in Florida for the length of treatment or come to weekly office

visits as per state regulations? ______________________________

History of benzodiazepine / Other drug or alcohol use: ___________

______________________________________________________

Medication 1:

What medication are you taking? ___________________________

Amount per day now? ____________________________________

Avg. amt per day for the past 30 days? _______________________

How long have you been taking this medication? _______________

For what reason _________________________________________

Is it prescribed to you by a physician?________________________

Do you take it as prescribed?_______________________________

Have you ever attempted to come off this medication before? _____

Outcome? _____________________________________________

Special Notes: __________________________________________

Medication 2:

What medication are you taking? ___________________________

Amount per day now? ___________________________________

Avg. amt per day for the past 30 days? ______________________

How long have you been taking this medication? ______________

For what reason ________________________________________

Is it prescribed to you by a physician? _______________________

Do you take it as prescribed?_______________________________

Have you ever attempted to come off this medication before? _____

Outcome?_____________________________________________

Special Notes: __________________________________________

Medication 3:

What medication are you taking?____________________________

Amount per day now?_____________________________________

Avg. amt per day for the past 30 days?_______________________

How long have you been taking this medication? _______________

For what reasons? _______________________________________

Is it prescribed to you by a physician?________________________

Do you take it as prescribed? ______________________________

Have you ever attempted to come off this medication before? _____

Outcome?______________________________________________

Special Notes: __________________________________________

Medical History:

Chronic Medical Conditions: _______________________________

Surgical History: _________________________________________

Daily Medications and Doses: ______________________________

Height______ Weight______ Date of Birth__________ Age_______

Describe in detail and listthe symptoms you experience currently:

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

PLEASE PRINT, COMPLETE AND FAX THIS COMPLETED
QUESTIONNAIRE TO: FAX– 561-290-1307

Disclaimer: Submission of this questionnaire does not guarantee acceptance into the program.
Your individual case will be reviewed and evaluated by our medical team to determine if you are an appropriate candidate for New Beginnings Recovery Center’s Benzodiazepine Detoxification Program.