/ . other (Specify) 19. Activity Restrictions (SPecify) 20. Abuse, substance/ Physical / emotional 21. Nutrition 22. Other B. HEALTH HISTORY (Seriousdllnesses I •• •r aM) (attach narrative if additional space needed) .:• C. LABORATORY (as indicated) • type Hernaglobin/Hematocrit Stool (O & PI T