PRIVACY ACT MATERIAL REMOVED ©
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
-
Sex
ff
Age 3
Residence:
1954-1960 — Cele lafber
1960-1966 — nd
1966-1972 — thee
197 2-
Snore
—
aescription of
pA.
symptoms:
T
Nherdbacles Gortey P
at Shakes a. L DALE Beetoner |
Paw
~~ ler
OrCo
Affect:i £6Cow
|
Surgery
7
Year —
Have you been receiving treatment for any illness for a perica
over xc one year?2?
<
Has anyone in your family complained of similar symptoms to cne
ones you are now experiencing?
5
Surgery? Op.
(Son )
Chey. C feel -aLl Ho C12)
“4
Signature
_
pate Sil
mus, 011015 PRIVACY ACT MATERIAL REMOVER