_ PRIVACY ACT MATERIAL REMOVED Majuro, Marsnali Islancs Special Healtn Survey Name . Sex M\ Age 7% nesidaence: 1954-1960 ~— Ut {Ke ul ayouU-15966 -_—_ 1972- _— Lite lc 1966-1972 _ Sc: Wo J eS SEARS tion hk 1 beer te fect Lenk (Mets: Yucgery \ coe SYMDCONS: . ; . PUA ARO : ae wos 5 $x, 8 ceect, - Ge ‘Lauer a7 fewed Leen © sf APU tree ce of Lech, <+ fi te-|\{ ithak Kieu . . [xan ~ | tw, wit Fe. —. , L{~ . oe oo Mee er / ) . . Year (TI heaner ftfrtin? ~~} / f va YOu peen receiving treatment for any illness for a perica OVers One year? US ain yone in your family conplained of sinilar. symptoms to tic ones Y Gu are now experiencing? a Surgery? Cf. rey. . . 4 v } i Signature 01 soo 2 ZL PRIVACY ACT MATERIAL REMOVED coho, pSoens webe Cee oo! Artur) — / o ome Levey. yo