Arizona Department of Economic Security

Tucson, AZ 85701

REQUESTED MEDICAL QUESTIONAIRE ON BEHALF OF
ARIZONA DEPARTMENT OF ECONOMIC SECURITY


December 12, 1997

Addressed too:
El Rio Clinic
Tucson, Ariona

From: Christopher Walters
Homeless Person
Tucson, Arizona

The Arizona Department of Economic Secuirty has requested information if possible wheather I am able or unable to work and I would ask your staff to address questions:

1. Chris Walters has history of treatmetn of Melanomas and extensive family history of immediate family who die from cancer. Should Chris Walters continue to follow instructions of physicians of record Dr. Posey in Alabama to avoid exposure to sun and activities such as day labor which cause extensive exposure to sun?

Can do day labor if wear long sleaves,hat,sun screen.

2. Can Chris Walters or any other person with an extensive 40 year history of gastro intestinal problems which result in involuntary bowel movements be gainfully employied prior to the problem being diagnosed, evaluated, and treated?

Is disagnosed and treated now

3. Can Chris Walters or any other person on a prescription medication Clindex or Librax which causes 20-30 bowel movements a day be gainfully emplyied prior to the problem being dignosed, evaluated, treated?

Circled NO: Write have fixed problem haven't have chance to evaluate new meds yet.

4. Does your staff understand the origional physical of record is Dr. Mark Fleisher a board certified Gastroenterologist of Tyler, Texas who prescribed:

a. Clines/Librax for treatment of spastic colon or possible stricture of decending colon?

b. Examination, Evaluation, Treatment by qualified Gastroenterologist, Dermagologist, and Onocologist?

c. Prescribed colonoscopy?

Circled Yes

By Signed G Evans FNP Dated: 12/12/97