PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name 7 oo . SEX 7*) Age & Residence: 1954-1960 — 1960-1966 1966-1972 197 2- OPEPG ft po ee, ee SNnoxrt se of symptons: Aivodnely, atu 2 Steen ae Lptani Surgery Trikedis pre ~ Year / [9 LL have you been receiving treatment for any iilness for a perica over one year? eo Has anyone in your family complained of similar symptoms to tne Ones you are now experiencing? Lad J Cte Farne) surgery? A/a, Signature . ate dele t gums 5011013 PRIVACY ACT MATERIAL REMOVED Lees