PRIVACY ACT MATERIAL REMOVED WALLY GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name Sex | - FE ar Age 4 Residence: 1954-1960 — yehoige 1960-1966 — °1966-1972 - Tae 197 2—_ ue Short sescviption of symptoms: x ’ Surgery Vv . - y Fe Senetg / Cl. , No is c : 5 e € oe t Year’ °° Have you been receiving treatment for any illness for a period Over one year? ( Has anyone in your family complained of similar symptoms to the ones you are now experiencing? ( Surgery? wo. Signature a , Date fry / 7 5011832 PRIVAGY AtT MATERIAL REMOVED a