2
PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
|
Sex
Age 4°
+
Name
Residence:
1954-1960 - - il”
1960-1966
- 1966-1972
L972-
.
°°
.
Short description of symptoms:
Surgery
.
.
‘
Continous
Ae
oS
Vain
\
\*
iN Mit Vor reck,
Year
Have you been receiving treatment for any illness for a period
a
Ae
6
over one year?>? YES
A
_
Has anyone in your family complained of similar symptoms to the
Ones you are now experiencing?
| -
\:~/
Surgery?
.
Signature
.
gums) 1822
Date
.
Zo f- ho,
6/ fy
PRIVACY ACT MATERIAL REMOVED