Relax Treat

Jeff Baker, Ph.D. - Course Coordinator - (409) 747-2250

Relaxation Treatment Submission Form

Student Last Name:
Student First Name:
Patient's Initials:
Patient Room #:
Relaxation Treat#

Patients Birth Year:
Patients Ethnicity:
Patients Gender:

Blood Pressure Before
Blood Pressure After
HR Before
HR After
Resp Before
Resp After
Date Treatment Delivered:

Self Rating of Interview (10=Perfect 5=Average 1=Poor:

Detailed Note Regarding Patient Interaction & Procedure:

Press submit below to forward this information to the instructor. You should receive a confirmation form if it was a successful submission. Save the confirmation form as a word document for your files and upload it to the WebCT under Relaxation Treatment Assignment. Ten Points are available for each correct submission. If the information is incorrect you can click on the back button of the browser, correct the information and re-submit.