PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro,
Marshall
Islands
Special Health Survey
Name
Sex
&
Age a
Residence:
1954-1960 — [r/of
1960-1966 — Wndee
1966-1972 _
1972 ~
— wt
WE
aw eos
Snore description of symptoms: Cleffeels
Surgery
Morpedel,
f
ae
Year
J
/
bvedlmy
FTF
Have you been receiving treatment for any illness for a perioa
over one year? ;
Wo
O
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing? 7s
Surgery? Lf,
(ITE Bex Tir)
Signature
.
7
|
?
biter
Date
6h 18I 4
’
if79
/ of
PRIVACY ACT MATERIAL REMOVED