1 / Mental Behavior Prob t8. Handicap. "seal. other (Specify) 19. Actrvty Restrictions (Specify' 20. Abuse. substance/ physcal / emotional 21 Nitrition 22 °the- B. HEALTH HISTOR(if (Serous Illnesses Injur•es explain) (attach narrative if additional snipe needed) C. LABORATORY (as indicated) It