a PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL Majuro, ISLANDS Marshall Islands Special Health Survey Name Sex = -- Age > 3 Residence: 1954-1960— Jenne AGL. 1960-1966 ~ jy ~ -1966-1972_ ie [we 1972- aes MeYee te it Short description of symptoms: Mentoet / Ate oat. a LE leJ f che iy Kiatteanrtan ltrk Surgery Fuchs ip He. foveal 72 é AOOilge Hegre lec lo. Year [HE 4 / liave you been receiving treatment for any illness for a pericu over one year? ; : Ae C4 pn . 77 CL che P37 . af f Segiccd } ~ ¢ Aopen a Dri C-Orf yk ‘ . fc “pet Has anyone in your family complained of similar symptoms to cnc ones you are now experiencing? Surgery? Date Signature game 5011809 Spiloa privacy ACT MATERIAL REMOVED