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Self-Report Form
Name: Date: Time:
Sex: F M Age: Group: A B C D
Level of Relaxation (pre-procedure):
Mental.
relaxed 1 2 3 4 5 6 7 8 9 10 tense
Physical.
relaxed 1 2 3 4 5 6 7 8 9 10 tense
Level of Relaxation (post-procedure):
Mental.
relaxed 1 2 3 4 5 6 7 8 9 10 tense
Physical.
relaxed 1 2 3 4 5 6 7 8 9 10 tense
Comments
Relaxation Response Handout
The relaxation response is an integrated mind/body reaction which has been found to have
such benefits as increased mental and physical health and improved ability to deal with tension
and stress. Some physiological components of the response are decreased oxygen
consumption, decreased respiratiry rate, decreased heart rate, and increased alpha brain
wave production. An individual’s ability to voluntarily control the relaxation response thus
enables a degree of control over these bodily processes. Also, gaining voluntary control of