PRIVACYACT MATERIAL REMOVED
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GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
;
|
~
-
Sex
[=
Age gb 2
Residence:
1954-1960 - / taaee
1960-1966
oN CON ew!
1966-1972
DS Gey
1972-
PTA KNCaN,
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Short description of symptoms:
reretecyins oth ghing 7
:
bod _ hcl mw
Surgery
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Year
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have you been receiving treatment for any illness for a perios
over
one year?
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eS aeee
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gn
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6
Cot
Eas anyone in your family complained of similar symptoms to tne
ones you are now experiencing?
i
Coy
Surgery?
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Signature
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|
Date
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PRIVACY ACT MATERIAL REMOVED
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