PRIVACY ACT MATERIAL REMOVED
—
. GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name.
_
_
Sex ok
Age
vad
Residence: L KIEP
1954-1960
1960-1966
1966-1972
1972-
Short description of symptoms:
~ Sore Throat,
- OFTex prevty eae Pe Voice, Voiceless
Surgery
—
oe
Year |
mave you been receiving treatment for any illness
over one year?
for a period
YES, ASTHMA .
aS anyone in your family complained of similar symptoms to the
ones you are now experiencing?
YES. Several or hem
Surgery?
Signature
—
oo
-
emmy 8828
_
Date
- STU79
avacy AGT MATERIAL REMOVED