PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name: sex | - Residence: 1954~1960 1960-1966 1966-1972, 1972- Age | ec Totl Lice AOL ta ~, LicigeP $$ MAULO MAUR Short description of symptoms: beahrle fees G, ictal, aet (i, lbs fy Fees ai Surgery (ay 20110 \ Year| rq] (09 IV | OPERATOR -- Have you been receiving treatment for any illness for a period over one Y year? 4 Os Has anyone in your family complained of similar symptoms to the ones you are now experiencing? vA £ f Surgery? Signature EE $ $ $e 5011845 saeAEUTF PRIVACY ACT MATERIAL REMOVED