PRIVACY ACT MATERIAL REMOVED
. GOVERNMENT OF THE MARSHALL ISLANDS
Majuro,
Marshall Islands
Special Health Survey
Name
Se@xX
oF
Age
SF
Residence:
1954-1960
1960-1966
1966-1972
1972-
_Ribs
_ We,
_ melee
_
7
Short description of symptoms: Pat (Ws ThE PACK,
SCesELLiny,
or EYES
Awd BTR Pps oe Tite fod4\ Gteaz Mendiheites, NERUPUSAESS.
GREAY Phew Of bom 1H AL
Surgery
PAW ,
Ulbits Cpectben(t 72a)
Year LA “Uy
Have you been receiving treatment for any illness for a period
over one year?
*6
C7,
SthApi
SA
re
Ape OIVE
CAHEATUAES .
Pat LIPf
Has anyone in your family complained of similar symptoms ‘to the
ys: (Fro£Sete2D
ones you are now experiencing?
Surgery? I ;
Signature
ay
a
O Spe = na
_—s:—séDatte obra
_——_
5011840
PRIVACY ACT MATERIAL REMOVED