PRIVACY ACT MATERIAL REMOVED
—
GOVERNMENT OF THE MARSHALL ISLANDS
Majuxo, Maxsnall Isiands
Special Health Survey
y
ti@
A
Sex Female ~
Rcssaence:
Age
_37
Likiep
1954-15960
1960-1966
1966-1972
i397 2t
~
2
“ore description of symptoms:
Surgery
‘Total Hysterectomy
Hydatiform mold
SS
Year’ 7677 0
Save you been receiving treatment for any illness for a perics
Over one year?
-.3 anvone in your family conpiained of sanilar symptoms to cne
Ones you are now experiencing?
surgery?
ed
Signature
_.
7 501183
7°
Date — SW /S7G.
PRIVACY ACT MATERIAL REMOVED