AMPLIFIED MUSCULAR PAIN SYNDROME (AMPS) IHP

Student's Name *
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DoB
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Address
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Treating Physician
Physician Phone Number
Physician Fax Number
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Nursing Diagnosis: Acute/Chronic Pain
Nursing Diagnosis: Impaired Physical Mobility
Nursing Diagnosis: Anxiety Related to Pain Episodes
Nursing Diagnosis: Ineffective Coping
Nursing Diagnosis: Risk for School Absenteeism
Nursing Diagnosis: Deficient Knowledge (Self-Management of Pain)
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IHP Developed By

Name
Date
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