PRIVACY ACT MATERIAL REMOVED . —_—— GUvVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Isiands Special Health Survey Name ~T Sex v 9 oo /= Age 7 Residence: 1954-1960 Steep 1960-1966 M7%1" 1966-1972 1972 JYiaqzur0 Peja , Snort description of symptoms: FO ay , a ( ‘eteooo patos , fevenr4, Atacrcbe, ) “MMru2negs ee a ee surgery So Year Have you been receiving treatment for any illness for a period over one year? GE sl(po co > Has anyone in your family complained of similar symptoms to the ones you are now experiencing? 2 es 7 Surgery? De. Signature ¥ a | —_ .... 2 , Date 6-/0. 7 Z PRIVACY ACT MATERIAL REMOVED