PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name Sex - Age rf Residence: 1954-1960 —LIK/E 1960-1966 — J /K} 1966-1972 _ Cheep! MATOIL| 1972- _ WATa eo Short description of symptoms: (eeEAT bern tht! Tie THLOAT, Bippitultiy (kh Sperpam HE PI, SteebLenT4 , pla, FEELING VE TEWSED , eelsGp ULERY WEAK. RE KECULT op Tenceness , MA VeabVeSs, HEADACHES Surgery Nor : Year: °° Os VE 7 / Have vou been receiving treatment for any illness for a period over one year? Mo Has anyone in your family complained of similar symptoms to the ones 7 you are now experiencing? P To surgery?ez , C 4 . Signature gem, Mile: VES - ) Date Gai 77 5011835 PRIVACY ACT MATERIAL REMOVED