PRIVACY ACT MATERIAL REMOVED
WALLY
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
Sex | - FE
ar
Age 4
Residence:
1954-1960 —
yehoige
1960-1966 —
°1966-1972 - Tae
197 2—_
ue
Short sescviption of symptoms:
x
’
Surgery
Vv
.
-
y
Fe
Senetg
/ Cl.
,
No is
c
:
5
e
€ oe
t
Year’ °°
Have you been receiving treatment for any illness for a period
Over one year?
(
Has anyone in your family complained of similar symptoms to the
ones you are now experiencing? (
Surgery?
wo.
Signature
a
, Date fry
/ 7
5011832
PRIVAGY AtT MATERIAL REMOVED
a