PRIVACY ACT MATERIAL REMOVED GOVERNMENT OP Cs Maturc, Sen 2OLAN OS mars: DSianas Speciai HeaTEE SULVEY Name | Sex fey Age 44 2954-1960 _ resé 1960-1966 hz “7 1966-1972 97° 1972Ate v Sucre cescription OFSymMpcoms cos : soy (Deeg - MSO, a Ay vf é Z ’ fe SULExeter ieee hunhecto-, , Surgery Year wove YOu been receiving treatment for any illness for a period OVELD O12 year? / pe Nis anyone in your family complained of similar symptoms to cne ones you are now experiencing? Dba Suzgery?’Jus , Signature: —_———_—_-_ oe en M501 1855 Tt... ———— Date 7 ANA , 7 PRIVACY ACT MATERIAL REMOVED