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SAMPLE INDIVIDUALIZED HEALTHCARE PLAN

Student Name: Date of Birth: Grade:

Primary Health Concern:

Secondary Health Concern(s):

Student Risk:

Nursing Diagnoses:

Action Items:

Anticipated Results:

.

Evaluation:

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Student Name: Date of Birth: Grade:

Primary Health Concern:

Secondary Health Concern(s):

Student Risk

Nursing Diagnoses:

Action Items:

Anticipated Results:

Evaluation: