PRIVACY ACT MATERIAL REMOVED
.
—_——
GUvVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Isiands
Special Health Survey
Name
~T
Sex
v
9
oo
/=
Age
7
Residence:
1954-1960
Steep
1960-1966
M7%1"
1966-1972
1972
JYiaqzur0
Peja
,
Snort description of symptoms:
FO
ay
,
a
(
‘eteooo patos , fevenr4,
Atacrcbe,
) “MMru2negs
ee a ee
surgery
So
Year
Have you been receiving treatment for any illness for a period
over one year? GE sl(po
co
>
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing?
2 es 7
Surgery? De.
Signature
¥
a
|
—_ .... 2
,
Date 6-/0. 7 Z
PRIVACY ACT MATERIAL REMOVED