n 22. Other B. HEALTH HISTO 3Y Serious Illnesses Inkursts: explain) (attach narrative if additional space needed) C. LABORATORY (as indicated) Hernoglobin/Hematoelt Stool (0 8 P) Tuberculin test: Lead NAME: TITLE: ADDRESS: (Please Pd ate type date results NRS-N Form 3040, Mar 91 cobseletes previous