PRIVACY ACT MATERIAL REMOVED GOVERNMENT Or THE MARSHALL ISLANDS Majuro, Marshail Islands Special Health Survey _ Name ah, Avtar AN we ities Sex ——jp—_—__ [= —~ RE,ag} i Tho om Age ¢ 1S S6 5 Residence: 1954-1960 — [gure 1960-1966 — br kaves 1966-1972 | 1972aes a i Ls Cte Short description of symptoms: PeedGone t vent” (7 lh [Aa surgery ét2. “Lh Feber liga L ; Pave, pTEELT AY a9 Fay /ietn. Aye 5 “i ArH DAU LEAPS oC relate foes v7 A C tof t ‘ Year / Have you been receiving treatment for any illness for a peric: over one year? Co [ee Has anyone in your family complained of similar symptoms to tic ones you are now experiencing? ¥ / i Loo Surgery? | Signature — _| , SO11814 Date 6 oa / hr ! PRIVACY ACT MATERIAL REMOVED “ lo