Soma Consent and Health History Form

Soma Institute of Structural Integration

Please complete and submit the following form before the start of your Soma Series. If you have any questions please let us know. All forms are HIPPA compliant.

We are looking forward to seeing you!

Thanks,

~ Team Soma
APPLICATION and CONSENT
I hereby apply for Soma Structural Integration bodywork and somatic education in the context of the Soma student clinic. I understand the intent is to improve the structure and functioning of my body and that the work is not represented as a substitute for medical care.

I recognize that the process of this educational experience necessitates that my body be touched, and I give permission to student practitioners and Soma faculty to touch my body. This consent form will apply to all Soma related treatment/sessions from this date forward, unless revoked in writing, for the duration of the training.

I understand that my paperwork/file will be retained by the Soma Institute. Beyond the cost for the session ($50), there is no additional charge for the work and the Institute will not bill any insurance as the work is being done by students, being supervised by instructors.
Photo Release (Optional)

Participants may be photographed or video taped during the workshop. These photos or videos may be included for Soma Institute publications or advertisements, including on our website and various social media sites. To ensure privacy, specific names of participants will not be included. No financial compensation shall be given for use of any photographs or video.

I acknowledge that the Soma Institute may choose not to use my photo or video at this time, but may do so at its own discretion at a later date. The Soma Institute reserves the right to discontinue use of photos or video without notice.

I consent to and authorize the use by the Soma Institute, or anyone authorized by the Soma Institite, of any and all photographs or video which have been taken of me .
Initial here to consent to Photo Release
I have received the Notice of Privacy Policy and have been provided an opportunity to review it. The Privacy Policy can be found here.

I have read and understood the above statements,
Name*

First NameLast Name
Signature*

Clear
Date

MonthDayYear
Date
Pronouns: Other:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com

Emergency Contacts: *

	Name	Relationship	Phone and Email
1
2

HEALTH AND FITNESS HISTORY
Age: Age Date of Birth: Date

Height: blanks Weight: blank
Please describe your previous experience with massage or bodywork.a question
Please indicate any current conditions and provide details as necessary. Any information you wish to provide is helpful.All information is confidential.

Abdominal PainAlcohol (specify daily average below)Allergies (specify below)AnxietyArthritis - specify Rheumatoid or Osteo belowCancerChest PainConstipationContact lensesDepressionDiabetesDigestive concernsEpilepsyFatigue (Specify time of day below)Frequent colds or fluHeadachesHeart DiseaseHernia or ruptureHigh or Low blood pressureKidney DiseaseLong CovidLung DiseaseNeurological ConcernsNicotine (specify daily average below)Painful feetPregnancyPMSTMJ DisorderTuberculosisSunisitisVaricose Veins/PjlebitisOther (specify below)
Please provide clarification on any conditions which were indicated above:
Are you under the care of a medical practitioner? (MD, chiropractor, naturopath, psychologist, etc If yes, please explain your condition.
List any medications you are using and their purpose:
Have you been hospitalized or had any major surgeries? Please explain.
Do you currently have any infectious conditions or diseases? Please explain.
Please describe any skin conditions you currently have. (rashes, athletes foot, eczema, etc)
Is there anything relating to your health which you are concerned about? Specific pains?

Please describe your history of accidents, injury, pain, soreness, stiffness, immobility, etc.,(include whiplash, scoliosis, broken bones, etc.) affecting the following areas:

	Detail
Cervical spine and head (neck, head)
Thoracic spine (upper, mid back)
Lumbar spine (lower back)
Sacrum and Hips
Extremities (legs, arms breaks, sciatica, carpal tunnel)
Joints (elbows, shoulders, ankles, knees, etc. - sprains, bursitis, swelling)
Other

Please describe any significant accidents, diseases, or ailments which you have experienced in the past five years that are not included above.
Relationships:

Mother alive?
Father alive?
Describe the significant relationships in your life.
Sleep:

Average hours of sleep per night blanks
On rising:   Refreshed   Tired   Depends

Exercise:

List activities:
Hours per day (avg):
Hours per week (avg):
Please describe your diet
How is your health preventing you from doing what you want to do with your life?
Why are you choosing to experience Structural Integration?
What is the most pleasing aspect of your life right now?
What is the most unsatisfactory part of your life?
How much responsibility do you assume for the situations in questions (2) and (3) above?
What is the best thing that could happen to you as a result of your experience with Soma Structural Integration?
What is the worst thing that could happen?
What do you like most about your body?
What do you like least about your body?
What is your earliest memory and how old were you at this time?
How did you hear about the Soma Institute?
Is there anything you wish to add?
Thanks for taking the time to fully complete this form. See ya soon!
Should be Empty:

APPLICATION and CONSENT

Pronouns: Please Select She/her/hers He/him/his They/them/theirs Other:

HEALTH AND FITNESS HISTORY

Relationships:

Sleep:

Exercise:

Pronouns: Other: