00%
PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
-
.
Residence :
SeX Of a
LIK/EP
1954-1960
1960-1966
‘1966-1972
1972-
—
Age 8
(2 )
f)
MAv aARD
Arol L.
(
|
BEEN WEAK ,
Short description of symptoms: Nenvinines &,
FAINTING)
Surgery
FEADACHE,
eee |
/
:
—_
year /7 La
Have you been receiving treatment for any illness for a period
over one year?
_—»
\Yes
°
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing?
Surgery?
Signature
|
.
_ Date
i Bbb
M Ade
PRIVACY ACT MATERIAL REMOVED