PRIVACY ACT MATERIAL REMOVED _ GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name | ; e Sex hh Age Jf Residence: 1954-1960 — ape NAATPLO 1960-1966 — Anh. Apri 1966-1972 ——- frp 2. Rd yas 1972- fief, — “lAtturLe Snore description of symptoms: Niffcantby fm™~ Speake y Lith [frees wo foros surgery Year have you been receiving treatment for any illness for a perica over one year? fm Has anyone in your family complained of similar symptoms to tne ones you are now experiencing? Pp ; , fa . Surgery? As. Signature - | . Date PAL ? /° J PRIVACY ACT MATERIAL REMOVED