2 PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey | Sex Age 4° + Name Residence: 1954-1960 - - il” 1960-1966 - 1966-1972 L972- . °° . Short description of symptoms: Surgery . . ‘ Continous Ae oS Vain \ \* iN Mit Vor reck, Year Have you been receiving treatment for any illness for a period a Ae 6 over one year?>? YES A _ Has anyone in your family complained of similar symptoms to the Ones you are now experiencing? | - \:~/ Surgery? . Signature . gums) 1822 Date . Zo f- ho, 6/ fy PRIVACY ACT MATERIAL REMOVED