PRIVACY ACT MATERIAL REMAVEN — GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name _ __ Sex [— Age dG Residence: 1954-1960 — frAiuee 1960-1966 . 1966-1972 — 197 2_ finrunt [“AApuwe , VAR TUM “Short Gescription of symptoms: furlLiht; FPAAN TTA G- Surgery VETWHEALK , Dekel distor / , WeMaef (reer parantet Dipl re TL 1ns : y y Bree ( eh LbnsbESS, | Year LZ DL nave you been receiving treatment for any illness ror a@ perics Over one year? year? Af, Has anyone in your family complained of similar symptoms to tuc ones you are now experiencing? NL é Surgery? Signature | Toate Jo / “a ae ii PRIVACY ACT MATERIAL REMOVED Hees p Mowe