PRIVACY ACT MATERIAL REMOVED
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.. GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
OO
a
.
Sex oo {
,
Age
27
Residence:
1954-1960— Kkuip
1960-1956 -— 777
23¢uter
1966-1972 — Wd:
1972a Weare
surgery
FEE
RR (Co (foe
MBL
Short description of symptoms:
CfDrtim
Aefos
C=
__
6
Le. Ts
(Deise
Year /°76
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? Ir
(
a
Surgery?
Signature |
a
‘Date
ho/o¢
ff
7%
PRIVACY ACT MATERIAL REMOVED