PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name oe | - Sex AA Age [7 Residence: 1954-1960 — /bATALO 1960-1966 —~ Lu — 1966-1972, ee 1972Det Snort description of symptoms: EXE Ae OAH ES7 Surgery Ste LIV ESS ‘F EK ERIAA z : ay cide[meg Year JP7 Have you been receiving treatment for any illness for a peric.s over one year? VS, Has anyone in your family complained of similar symptoms to ene ones you are now experiencing? LE Nie Surgery? NMOL ay Signature | a oo B501112 Date Le 5 Hai ff #- PRIVACYACT MATERIAL REMOVED