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| Benzodiazepine 1
| {{{field|benzo1|mandatory|values from category=Benzodiazepine}}}
| {{{field|dose1|mandatory|input type=Number|size=5}}}
| mg/day
|-
| Benzodiazepine 2
| {{{field|benzo2|values from category=Benzodiazepine}}}
| {{{field|dose2|input type=Number|size=5}}}
| mg/day
|-
| Benzodiazepine 3
| {{{field|benzo3|values from category=Benzodiazepine}}}
| {{{field|dose3|input type=Number|size=5}}}
| mg/day
|-
| Benzodiazepine 4
| {{{field|benzo4|values from category=Benzodiazepine}}}
| {{{field|dose4|input type=Number|size=5}}}
| mg/day
|-
| Benzodiazepine 5
| {{{field|benzo5|values from category=Benzodiazepine}}}
| {{{field|dose5|input type=Number|size=5}}}
| mg/day
|-
