PRIVACY ACT MATERIAL REMOVED
ULF
wJVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
Sex Fo
Age Fb Gea
Residence:
1954-1960
freee
1960-1966
Ahiry-
1966-1972
1972-
1
A heil-
Short description of symptoms:
CO)
Ceecac. U brats
GS tle
tm
Ero ettirniiiicty
Surgery
-let
ord
mo
ea
Year —
fave you been receiving treatment for any illness for a period
over one year? ge fre
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing? Ge
Surgery?
Signature
yut
oe
cd
Cv
-
m5 2s
Date
Z/1 /o7
PRIVACY ACT MATERIAL REMOVED