PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro,
,
Name.
Marshall
Islands
Special Health Survey
/
Sex
:
E
Age
SC
J pra 19°F
Residence:
1954-19607
Bam mm Clk - GR —
1960-1966
1966-1972
'1972-
Short description of symptoms:
loss of Han'r
;
Surgery
Dy. bbe8
ge
[Pryjad x “an
4)
Year
Have you been receiving treatment for any illness for a pericé
over one year?
Has anyone in your family complained of similar symptoms to tac
Ones you are now experiencing?
Son
asso
vv oprcted m Ay
Wrens
: Kent,
Surgery?
Signature
Date
e
=
5011860
PRIVACYACTMATERIAL REMO
VED