PRIVACY ACT MATERIAL REMOVED
ee
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro,
Marshall Islands
Special Health Survey
Name
;
Residence:
Sex Male
Age
14
Likiep
1954-1960
1960-1966
1966-1972
1972-
Short description of symptoms:
Surgery
Cleft Palate
Cleft Palate Correction (Three Times) Year 1968 “(Guam Memorial Hospital)
Have you been receiving treatment for any illness for a period
over one year?
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing?
Surgery?
Signature
--
a
-
gummy 50115937
Date
_
SULT 5
PRIVACY ACT MATERIAL REMOVED