PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name | : - 7 ” ' , Sex SLY Age LO Residence: 1954-1960 — WT. 1960-1966 _— 4, 1966-1972 __ 1972- — * Short description of symptoms: oe We Leckhe, } beadsLe Geta Rerperorrees oodfasts - Jeep MCLG thttt ) Surger gery Tk 7 ROD CURRFOV 7 L 25 XY ear A22 7 Have you been “Cfo, CHE treatment for any illness for a period over one year? a Cpe . -) Has anyone in your family complained of similar symptoms to tne ones you are now experiencing? O Surgery? Signature : _ 7 JO1 1843 ny “pate | Pe [29 7777 PRIVACY ACT MATERIAL REMOVED Ll ——/