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{{{for template|CalculateBenzo}}}
{| class="formtable"
| colspan="4" | <center>Choose one or more benzodiazepines and dosage expressed as mg/day</center>
|-
!
! Benzodiazepinesdrug! dosage! mg/day
|-
| Benzodiazepine 1
| {{{field|benzo1|mandatory|values from category=Benzodiazepine}}}
| {{{field|dose1|mandatory|input type=Number}}} | mg/day
|-
| Benzodiazepine 2
| {{{field|benzo2|values from category=Benzodiazepine}}}
| {{{field|dose2|input type=Number}}} | mg/day
|-
| Benzodiazepine 3
| {{{field|benzo3|values from category=Benzodiazepine}}}
| {{{field|dose3|input type=Number}}} | mg/day
|-
| Benzodiazepine 4
| {{{field|benzo4|values from category=Benzodiazepine}}}
| {{{field|dose4|input type=Number}}} | mg/day
|-
| Benzodiazepine 5
| {{{field|benzo5|values from category=Benzodiazepine}}}
| {{{field|dose5|input type=Number}}} | mg/day
|}
{{{end template}}}
</includeonly>