PRIVACY ACT MATERIAL REMOVED
GOVERNMENT Or THE MARSHALL ISLANDS
Majuro, Marshail Islands
Special Health Survey
_
Name
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ities
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Age
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Residence:
1954-1960 — [gure
1960-1966 — br kaves
1966-1972
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1972aes
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Short description of symptoms:
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surgery
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Year
/
Have you been receiving treatment for any illness for a peric:
over one year?
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Has anyone in your family complained of similar symptoms to tic
ones you are now experiencing? ¥
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Surgery?
|
Signature
—
_|
,
SO11814
Date
6
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/ hr !
PRIVACY ACT MATERIAL REMOVED
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