00% PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name - . Residence : SeX Of a LIK/EP 1954-1960 1960-1966 ‘1966-1972 1972- — Age 8 (2 ) f) MAv aARD Arol L. ( | BEEN WEAK , Short description of symptoms: Nenvinines &, FAINTING) Surgery FEADACHE, eee | / : —_ year /7 La Have you been receiving treatment for any illness for a period over one year? _—» \Yes ° Has anyone in your family complained of similar symptoms to the ones you are now experiencing? Surgery? Signature | . _ Date i Bbb M Ade PRIVACY ACT MATERIAL REMOVED