PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name:
sex | -
Residence:
1954~1960
1960-1966
1966-1972,
1972-
Age |
ec
Totl
Lice
AOL
ta
~,
LicigeP $$ MAULO
MAUR
Short description of symptoms: beahrle
fees
G,
ictal, aet (i, lbs
fy
Fees ai
Surgery
(ay 20110
\
Year| rq] (09 IV |
OPERATOR --
Have you been receiving treatment for any illness for a period
over
one
Y
year?
4 Os
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing?
vA
£
f
Surgery?
Signature
EE
$ $ $e
5011845
saeAEUTF
PRIVACY ACT MATERIAL REMOVED