Soma Wellness Screening Form

Soma Institute Wellness Screening Form

Health Disclosure
Date & Time
In order to reduce the risk of spreading COVID-19, the Soma Institute of Structural Integration requires anyone entering the Soma Institute campus to answer a number of “screening” questions. It is important that you truthfully disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

You are required to disclose the status of your health every week that you come to the Soma Institute. You will not be allowed to enter without first completing this health screening.

Some symptoms of COVID-19 can mimic other conditions like allergies and other illnesses. Regardless, if you are experiencing these symptoms, you must report them prior to entering the Soma Institute. Answering "yes" to a question does not necessarily mean that you will not be allowed to enter. Rather it will give us the opportunity to properly screen you and do our part to prevent the spread of COVID-19 and other contagious diseases.

For the safety of the whole Soma Institute community, please be truthful and candid in your answers.
Name:*

First NameLast Name
Covid-19 Vaccination Information:

Not VaccinatedFully VaccinatedPartially Vaccinated
Person administering Wellness Screening (if different than above):

First NameLast Name
Relation to the Soma Institute:
Model, student, teacher etc.
Name of Student Practitioner, if applicable:
Student Name
PRE-EXISTING CONDITIONS— Please check the box if it applies to you:

Underlying heart condition and/or cardiovascular diseaseDiabetesChronic Lung DiseaseSuppressed immune system functionOther
GENERAL SYMPTOMS— In the last 14 days, have you experienced any of the following? Please check the box if any of the following apply to you:*

Shortness of breath or trouble breathing.Dry or productive cough.Fever or above normal temperature (100.4). Chills.Runny nose.Muscle or joint aches and pain.Purple, blue or white fingertips or toes.Headache.Recently lost or had a reduction in your sense of smell or taste.Sore throat.Nausea or vomiting. Experiencing diarrhea.No Symptoms.Other
COVID-19 EXPOSURE— Please check the box if any of the following apply to you within the last 4 weeks:*

I have been in contact with someone who has tested positive for COVID-19 or had a positive antibody test.I have been tested for COVID-19 and am awaiting results.I have been self-quarantined.None of the above apply to me.Other
Have there been any changes you'd like to bring attention to since your last visit to the Soma Institute?
Is there anything you would like to add?
By signing below, or having a student practitioner sign on my behalf, I understand that by inaccurately answering the COVID-19 questions above, I put my Soma community's health at risk. I have answered the COVID-19 screening questions truthfully or to the best of my ability.
Signature:*

Clear
Staff Use Only:
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Soma Institute Wellness Screening Form