PRIVACY ACT MATERIAL REMOVED . GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name Se@xX oF Age SF Residence: 1954-1960 1960-1966 1966-1972 1972- _Ribs _ We, _ melee _ 7 Short description of symptoms: Pat (Ws ThE PACK, SCesELLiny, or EYES Awd BTR Pps oe Tite fod4\ Gteaz Mendiheites, NERUPUSAESS. GREAY Phew Of bom 1H AL Surgery PAW , Ulbits Cpectben(t 72a) Year LA “Uy Have you been receiving treatment for any illness for a period over one year? *6 C7, SthApi SA re Ape OIVE CAHEATUAES . Pat LIPf Has anyone in your family complained of similar symptoms ‘to the ys: (Fro£Sete2D ones you are now experiencing? Surgery? I ; Signature ay a O Spe = na _—s:—séDatte obra _——_ 5011840 PRIVACY ACT MATERIAL REMOVED