PRIVACY ACT MATERIAL REMOVED ULF wJVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name Sex Fo Age Fb Gea Residence: 1954-1960 freee 1960-1966 Ahiry- 1966-1972 1972- 1 A heil- Short description of symptoms: CO) Ceecac. U brats GS tle tm Ero ettirniiiicty Surgery -let ord mo ea Year — fave you been receiving treatment for any illness for a period over one year? ge fre Has anyone in your family complained of similar symptoms to the ones you are now experiencing? Ge Surgery? Signature yut oe cd Cv - m5 2s Date Z/1 /o7 PRIVACY ACT MATERIAL REMOVED