PRIVACY ACT MATERIAL REMAVEN
—
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
_
__ Sex
[—
Age dG
Residence:
1954-1960 — frAiuee
1960-1966 .
1966-1972 —
197 2_
finrunt
[“AApuwe
,
VAR TUM
“Short Gescription of symptoms:
furlLiht;
FPAAN TTA G-
Surgery
VETWHEALK ,
Dekel distor
/
, WeMaef
(reer parantet
Dipl re
TL 1ns
:
y
y Bree (
eh LbnsbESS,
|
Year LZ DL
nave you been receiving treatment for any illness ror a@ perics
Over one
year?
year?
Af,
Has anyone in your family complained of similar symptoms to tuc
ones you are now experiencing? NL
é
Surgery?
Signature
|
Toate
Jo
/
“a
ae
ii
PRIVACY ACT MATERIAL REMOVED
Hees
p
Mowe