PRIVACY ACT MATERIAL REMOVED — GOVERNMENT OF THE MARSHALL ISLANDS Majuxo, Maxsnall Isiands Special Health Survey y ti@ A Sex Female ~ Rcssaence: Age _37 Likiep 1954-15960 1960-1966 1966-1972 i397 2t ~ 2 “ore description of symptoms: Surgery ‘Total Hysterectomy Hydatiform mold SS Year’ 7677 0 Save you been receiving treatment for any illness for a perics Over one year? -.3 anvone in your family conpiained of sanilar symptoms to cne Ones you are now experiencing? surgery? ed Signature _. 7 501183 7° Date — SW /S7G. PRIVACY ACT MATERIAL REMOVED