PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
7
oo
.
SEX
7*)
Age
&
Residence:
1954-1960 —
1960-1966 1966-1972
197 2-
OPEPG ft po ee, ee
SNnoxrt se
of symptons:
Aivodnely,
atu 2
Steen
ae Lptani
Surgery Trikedis pre ~
Year
/
[9 LL
have you been receiving treatment for any iilness for a perica
over one year?
eo
Has anyone in your family complained of similar symptoms to tne
Ones you are now experiencing?
Lad
J
Cte Farne)
surgery? A/a,
Signature .
ate
dele
t
gums 5011013
PRIVACY ACT MATERIAL REMOVED
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