a
PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL
Majuro,
ISLANDS
Marshall Islands
Special Health Survey
Name
Sex
=
--
Age > 3
Residence:
1954-1960— Jenne AGL.
1960-1966 ~ jy
~
-1966-1972_ ie [we
1972-
aes
MeYee
te
it
Short description of symptoms:
Mentoet /
Ate oat. a LE leJ f che iy
Kiatteanrtan
ltrk
Surgery
Fuchs
ip He. foveal
72 é AOOilge
Hegre lec lo.
Year
[HE 4
/
liave you been receiving treatment for any illness for a pericu
over one year?
;
:
Ae C4 pn
.
77
CL che
P37
.
af
f
Segiccd }
~ ¢
Aopen
a
Dri C-Orf yk
‘
.
fc “pet
Has anyone in your family complained of similar symptoms to cnc
ones you are now experiencing?
Surgery?
Date
Signature
game
5011809
Spiloa
privacy ACT MATERIAL REMOVED