PRIVACY ACT MATERIAL REMOVED oe =~++3RNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name — Sex <A Age & Residence: 1954-1960 Kfat 1960-1966 _.. 1966-1972 1972~~ Short description of symptoms: Oo D Rese of aelee fpeoctache, + Chie D npbirnrmation ofche Chroot Surgery ce Ylenre Year °° nave you been receiving treatment for any illness for a period Over one year? Gta? . Has anyone in your family complained of similar symptoms to the ones you are now experiencing? Gras Surgery? Yume Signature ae — ‘ . | Date sollaz) Ure SLO[77 , PRIVACY ACT MATERIAL REMOVED