PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
Sex -
Age rf
Residence:
1954-1960 —LIK/E
1960-1966 — J /K}
1966-1972 _ Cheep! MATOIL|
1972-
_ WATa eo
Short description of symptoms:
(eeEAT bern
tht! Tie THLOAT,
Bippitultiy (kh Sperpam HE PI, SteebLenT4 ,
pla, FEELING VE
TEWSED , eelsGp ULERY
WEAK. RE KECULT
op Tenceness , MA VeabVeSs, HEADACHES
Surgery
Nor
:
Year: °°
Os
VE 7
/
Have vou been receiving treatment for any illness for a period
over one year?
Mo
Has anyone in your family complained of similar symptoms to the
ones
7
you are now experiencing?
P
To
surgery?ez ,
C
4
.
Signature
gem,
Mile: VES
-
)
Date Gai
77
5011835
PRIVACY ACT MATERIAL REMOVED