PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey oO 7 . $ Name Residence: ; sex /1 7 Age Ss] . 1954-1960 fh A 1960-1966 Kidkekeg gf 1966-1972 1972Ge “oo Short gescription of < symptoms: ek, Surgery EVERLAST1 SF (Guofed AADAYS |. G reget) co 7] Year Have you been receiving treatment for any illness for a period over one year? C1 Has anyone in your family complained of similar symptoms to the ones you are now experiencing? Surgery? Signature “WY. a — 0011830. 7 . “ oe Delf PRIVACY ACT MATERIAL REMOVED