ify) 19. Activity Restrictions (Specify) 20. Abuse. substance/ physical / emotional 21. Nutntion 22 Other B. HEALTH HISTORY Serious Illnesses Infuriesi explain) (attach narrative if additional space needed) C. LABORATORY pvicl ted) Heriluglobing LoiertuLrit t:-/ • Stool (O 8 13) Tubercul