PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
oO
7
.
$
Name
Residence:
;
sex
/1
7
Age Ss]
.
1954-1960 fh A
1960-1966 Kidkekeg gf
1966-1972
1972Ge
“oo
Short gescription of
<
symptoms:
ek,
Surgery
EVERLAST1
SF
(Guofed
AADAYS |.
G
reget)
co
7]
Year
Have you been receiving treatment for any illness for a period
over one year?
C1
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing?
Surgery?
Signature
“WY.
a
—
0011830.
7
.
“
oe
Delf
PRIVACY ACT MATERIAL REMOVED