PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name ; ¥ . _ Sex_ Ff oo Age 3/ Residence: 1954-1960 — Lueree 1956 1960-1966 — (WRTuURD 1966-1972 v 197 2- Short description of. symptoms: Newoawes, eSpebes 7A n). OPERATIon) a surgery Yeo Year| 1996 So Have you been receiving treatment for any rllness for a period over one year? %ES Has anyone in your family complained of similar symptoms to the ones you are now experiencing? surgery? Signature _ 5011938 eed TE, Date May zs 979 PRIVACY ACT MATERIAL REMOVED