PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OP Cs
Maturc,
Sen 2OLAN OS
mars:
DSianas
Speciai HeaTEE SULVEY
Name
| Sex
fey
Age
44
2954-1960 _ resé
1960-1966 hz “7
1966-1972 97°
1972Ate
v
Sucre cescription OFSymMpcoms
cos :
soy
(Deeg
-
MSO, a
Ay
vf
é
Z ’
fe
SULExeter ieee
hunhecto-,
,
Surgery
Year
wove YOu been receiving treatment for any illness for a period
OVELD O12 year?
/
pe
Nis anyone in your family complained of similar symptoms to cne
ones you are now experiencing? Dba
Suzgery?’Jus
,
Signature:
—_———_—_-_
oe
en
M501 1855
Tt...
————
Date 7
ANA
,
7
PRIVACY ACT MATERIAL REMOVED