PRIVACY ACT MATERIAL REMOVED GOVERNMENT OF THE MARSHALL ISLANDS Majuro, , Name. Marshall Islands Special Health Survey / Sex : E Age SC J pra 19°F Residence: 1954-19607 Bam mm Clk - GR — 1960-1966 1966-1972 '1972- Short description of symptoms: loss of Han'r ; Surgery Dy. bbe8 ge [Pryjad x “an 4) Year Have you been receiving treatment for any illness for a pericé over one year? Has anyone in your family complained of similar symptoms to tac Ones you are now experiencing? Son asso vv oprcted m Ay Wrens : Kent, Surgery? Signature Date e = 5011860 PRIVACYACTMATERIAL REMO VED