_
PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Isiands
Special Health Survey
Name ere Sex
A
Age J¥
Residence:
1954-1960 —~
1960-1966
1966-1972
Kreatalernn
Nt47tt hie
bp AFerure
Snort description of symptoms:
ELL]
Atl
(PAK y ATK TIVE,
Lere
CP
KKraphlopics
NET? bole {MESS ,
“
FEL /te &-
Kerl: 17
Les Tle. Spee2 4 Al) THe Tivo
Fife
Surgery
Bey Kop DPBhIeTmny
Year
MenGe
(? EI
Have you been receiving treatment for any illness for a pexvice
Over one year?
A’ Lo!
AL bo Ao
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing?
fUO
Surgery?
Signature _
gpm
.
.
oe
STO
Date
™
c
fel
bpivacy ACT MATERIAL REMOVED
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