Danny Cameron

 
 1010700320067 
 13f377905001 
 Claim Number 2 
 Claim Number 3 
 
 PLEASE ANSWER THE FOLLOWING QUESTIONS FULLY: 
 How was your evaluating doctor selected? (check one) 
 From a list of doctors provided by the State of California, Division of Workers' Compensation. 
 Other (explain) 
 What is the of the doctor who will be doing the evaluation? Paulette Cass, ,D.C. 
 name 
 When is your examination scheduled? 
 February 26, 2023
 What were your job duties at the time of your injury? 
 COOK, 
 What is the disability resulting from your injury? 
 Injury to back, rightarm right shoulder. 
 How does this injury affect you in your work? 
 Aggravated with bending, lifting, pushing, pulling standing, 
 walking, reaching. 
 Have you ever had a disability as a result of another injury or illness? 
 no 
 If so, when? 
 Please describe the disability? 
 Date 
 June 17, 2022
 Signature Florentino Mejia 
 Gallegos 
 MM/DD/YYYY 
 DWC-AD form100 (DEU) Page 2 (REV. 11/2008) 
 DWC-AD form 100 (DEU) 
 375
