PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name a Sex Residence: - : age V/ \ 1954-1960 Ay 1960-1966 1966-1972 _1972- a . an ae Short description of symptoms: Surgery — ferbeufer, Chapuck Operelen Year 4 LLp 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? Ap Surgery? Signature ~ | ae: ; SO0118%2 cantil79 [l / | PRIVACY ACT MATERIAL REMOVED