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input type=dropdown| was default, moet nu expliciet gegeven worden
|-
| Benzodiazepine 1
| {{{field|benzo1|mandatory|input type=dropdown|values from category=Benzodiazepine}}}
| {{{field|dose1|mandatory|input type=Number|size=5}}}
| mg/day
|-
| Benzodiazepine 2
| {{{field|benzo2|input type=dropdown|values from category=Benzodiazepine}}}
| {{{field|dose2|input type=Number|size=5}}}
| mg/day
|-
| Benzodiazepine 3
| {{{field|benzo3|input type=dropdown|values from category=Benzodiazepine}}}
| {{{field|dose3|input type=Number|size=5}}}
| mg/day
|-
| Benzodiazepine 4
| {{{field|benzo4|input type=dropdown|values from category=Benzodiazepine}}}
| {{{field|dose4|input type=Number|size=5}}}
| mg/day
|-
| Benzodiazepine 5
| {{{field|benzo5|input type=dropdown|values from category=Benzodiazepine}}}
| {{{field|dose5|input type=Number|size=5}}}
| mg/day
|-
| '''Conversion drug'''
| colspan="3" | {{{field|replacement|mandatory|input type=dropdown|values=diazepam,oxazepam,chlordiazepoxide|default=diazepam }}}
|}
{{{end template}}}