ANXIETY

Student's Name *
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DoB
Would you like to add the student's ID number?
Would you like to add the student's homeroom number and teacher's name?

Address
Emergency Contact List is attached to IHP.

Treating Physician
Physician Phone Number
Physician Fax Number

Add a medication or procedure?

Nursing Diagnosis: Anxiety
Nursing Diagnosis: Ineffective Coping
Nursing Diagnosis: Fear related to Academic Performance
Nursing Diagnosis: Social Isolation
Nursing Diagnosis: Disturbed Sleep Pattern
Would you like to add another nursing diagnosis?

IHP Developed By

Name
Date
Do you want to include physician and parent signature lines?
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