PRIVACY ACT MATERIAL REMOVED — . GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name. _ _ Sex ok Age vad Residence: L KIEP 1954-1960 1960-1966 1966-1972 1972- Short description of symptoms: ~ Sore Throat, - OFTex prevty eae Pe Voice, Voiceless Surgery — oe Year | mave you been receiving treatment for any illness over one year? for a period YES, ASTHMA . aS anyone in your family complained of similar symptoms to the ones you are now experiencing? YES. Several or hem Surgery? Signature — oo - emmy 8828 _ Date - STU79 avacy AGT MATERIAL REMOVED