PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
7
Sex
x
Age S/
Residence:
1954-1960 — Arlulo thin UMA
1960-1966
1966-1972
197 2-
.
caort description of symptoms:
Surgery
Theyret dechons
Year|
LITVS
Haye you been receiving treatment for any illness for a cerics
OveL one year?
‘
Hus anvone in your family complained of similar symptoms to .v..O4eS you are now experiencing?
2 dletioes — Sedfoy K haan,
Sucgery?
Signature
M501 500
Date
PRIVACY ACT MATERIAL REMOVED