PRIVACY ACT MATERIAL REMOVED
_
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
|
;
e
Sex
hh
Age Jf
Residence:
1954-1960 — ape NAATPLO
1960-1966 —
Anh. Apri
1966-1972 ——- frp 2. Rd yas
1972-
fief, — “lAtturLe
Snore description of symptoms:
Niffcantby
fm™~
Speake y
Lith
[frees wo foros
surgery
Year
have you been receiving treatment for any illness for a perica
over one year?
fm
Has anyone in your family complained of similar symptoms to tne
ones you are now experiencing? Pp
;
,
fa
.
Surgery? As.
Signature
-
|
.
Date
PAL ?
/° J
PRIVACY ACT MATERIAL REMOVED