Soma Institute 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 assess your condition to determine whether or not to attend your session. If your responses raise any questions regarding whether to come in, please call the Soma Institute at 360-680-3053x3 and our clinic staff will be happy to assist.

You are required to disclose the status of your health every time you intend to come to the Soma Institute. You will not be allowed to enter without first completing this health screening. Ideally these questions are answered 24 - 48 hours prior to your visit so a proper assessment can be made.

It is important you 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.

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 Name Last Name
Phone Number *

Area Code Phone Number
COVID-19 EXPOSURE— An “Exposure” is defined as being within six feet of someone who is showing symptoms of COVID-19, for at least 15 minutes, or an infected person who shows no symptoms but later tests positive for the coronavirus. This is considered exposure regardless of whether one or both parties were wearing a mask.
Exposure— Please Choose: *

I was exposed within the last 5 days I was exposed 5 to 10 days ago I was exposed more than 10 days ago This does not apply to me
Please contact the clinic at 360.680.3053x3 to alert us to the situation.

We will be in contact to reschedule your session.
Please contact the clinic at 360.680.3053x3 to alert us to your situation.

We will help determine if you should attend your session.
If you have not experienced any symptoms OR you have a negative test result since exposure (ideally at 5 days from exposure) you may attend your session. Otherwise, please give us a call at 360.680.3053x3.
Positive Test for Covid within last 4 weeks — Please Choose *

I tested positive within the last 5 days I tested positive between 5 and 10 days ago I tested positive more than 10 days ago This does not apply to me
Please contact the clinic at 360.680.3053x3 to alert us to your situation.

We will work with you to determine if and when your next session can be scheduled.
Please contact the clinic at 360.680.3053x3 to alert us to your situation.

We will determine if it is possible for you to attend your session. To return to the clinic, the Institute requires a negative test result. The test should be taken 5 days or more after testing positive.
A negative test is required to return to the clinic. The test should have been taken 5 days or more after testing positive for Covid.
PRE-EXISTING CONDITIONS— If you have any of the following you are at a higher risk of complications from Covid-19, therefore we do not recommend you receive treatment. Please check the box if it applies to you: *

Underlying heart condition and/or cardiovascular disease Diabetes Chronic Lung Disease Suppressed immune system function None
Have you had Covid more than 4 weeks ago? *

Yes No
GENERAL SYMPTOMS— In the last 10 days, have you experienced any of the following as new symptoms? 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.
Have there been any changes you'd like to bring attention to since your last session?
Is there anything you would like to add?
By signing below, 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:
Should be Empty: