PRIVACYACT MATERIAL REMOVED we GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name ; | ~ - Sex [= Age gb 2 Residence: 1954-1960 - / taaee 1960-1966 oN CON ew! 1966-1972 DS Gey 1972- PTA KNCaN, ‘i Short description of symptoms: reretecyins oth ghing 7 : bod _ hcl mw Surgery / “ oy . Ens, 47 4 +; , —--/. Th . ‘ ’ H Nop oyeadheme] Year [ez- ~\ 7D Ue have you been receiving treatment for any illness for a perios over one year? ‘ eS aeee . pap gn ’ Lo —-y 6 Cot Eas anyone in your family complained of similar symptoms to tne ones you are now experiencing? i Coy Surgery? ff. Signature P| i, s011a) | Date ! vi . . a7 OnFT ean s [omy ; re .~ oo (. Lit , ° etal Les fe AECA EYIY , PRIVACY ACT MATERIAL REMOVED “