Rest, Relaxation, and Recovery Assessment Form
This questionnaire helps us understand your current rest, relaxation, and recovery patterns. Your answers allow us to personalize your BrainTap and HydroHeal sessions for optimal results. Please answer honestly — there are no right or wrong responses.
Client Information
Full Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Phone
Text
Email
Sleep Habits
On average, how many hours of sleep do you get per night?
Less than 5
5–6
7–8
More than 8
How would you rate the quality of your sleep?
Excellent
Good
Fair
Poor
How often do you wake up feeling refreshed and energized?
Always
Often
Sometimes
Rarely
Do you have difficulty falling asleep or staying asleep?
Yes
No
What factors most affect your sleep quality?
Stress or anxiety
Technology use before bed
Noise or light
Pain or discomfort
Irregular schedule
Other
Relaxation & Recovery
How often do you intentionally schedule time for relaxation?
Daily
Several times a week
Occasionally
Rarely
Which relaxation activities do you practice regularly?
Meditation or mindfulness
Deep breathing
Listening to calming music
Yoga or stretching
Reading or journaling
Nature walks or quiet time
None of the above
How long does it usually take for you to feel relaxed after stress?
Immediately
Within an hour
Several hours
A full day or more
When you experience stress, how do you typically respond?
Stay calm and use relaxation tools
Feel tense but manage it
Become overwhelmed or anxious
Shut down or withdraw
Mind–Body Awareness
How connected do you feel to your body’s signals for rest(fatigue, tension, burnout)?
Very aware
Somewhat aware
Not very aware
Not at all
Do you experience any of the following regularly?
Brain fog or trouble focusing
Headaches or muscle tension
Irritability or mood swings
Low energy or motivation
None of the above
On a scale of 1–10, how satisfied are you with your current rest and relaxation routine? (Linear scale — 1 = Not satisfied, 10 = Completely satisfied)
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Submit
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