PRIVACY ACT MATERIAL REMOVED
oe
=~++3RNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
—
Sex
<A
Age
&
Residence:
1954-1960
Kfat
1960-1966 _..
1966-1972
1972~~
Short description of symptoms:
Oo
D
Rese of aelee
fpeoctache, +
Chie
D npbirnrmation ofche Chroot
Surgery
ce
Ylenre
Year °°
nave you been receiving treatment for any illness for a period
Over one year? Gta?
.
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing? Gras
Surgery?
Yume
Signature
ae
—
‘
.
|
Date
sollaz)
Ure
SLO[77
,
PRIVACY ACT MATERIAL REMOVED