Medical History Questionnaire Form - Municipal Fire And Police Retirement System Of Iowa
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3Municipal Fire and Police Retirement System of Iowa
Medical History Questionnaire – To Be Completed by the Applicant
NAME:________________________________________
DATE:__________________
JOB TITLE: ____________________________________
PHONE: ________________
DOB: ___________ SSN: _________________________
AGE: ___________________
TYPE OF EXAM:
Post Offer
Medical Surveillance
Other
Mark “yes” or “no” to the following questions. For EVERY answer marked “YES,” please provide
an explanation in the space provided on the next page. For injuries you must specify the
location of the injury, i.e. right ankle or left ankle; right knee or left knee, etc.
HAVE YOU EVER HAD:
Yes
No
HAVE YOU EVER HAD:
Yes
No
Allergic reactions to medicines…
Stomach ulcers…………………..
HAVE YOU EVER HAD:
Yes
No
Ankle sprain(s)…………………..
Allergic reactions to chemicals,
Frequent nausea………………...
oils, or foods ……………………..
Any other bone/joint problems…
Frequent bowel trouble………....
Skin rashes or eczema……….….
Yes
No
Frequent diarrhea………………..
Asthma/wheezing………………...
DO YOU WEAR GLASSES:
Hernia……………………………..
Hay fever………………………….
For reading…………...
Bloody or black stools………….
Bronchitis………………………….
For distance………….
Any other stomach/bowel
Shortness of breath while
diseases or problems………..….
Do you wear contact lenses……
walking…………………………….
Loss of consciousness………….
Tightness of chest………………..
Are you color blind/impaired……
Fits, convulsions, or seizures…..
Persistent cough or phlegm……..
Other vision problems…….…….
Frequent hand/forearm pain……
Tuberculosis………………………
Any difficulties with vision at
Numbness of hands and/or
night……………………………….
Pneumonia………………………..
feet………………………………..
Emphysema………………………
Decrease in grip strength……….
HAVE YOU EVER HAD:
Yes
No
Sleep apnea………………………
Severe headaches………………
Ear surgery……………………….
Do you use tobacco products? *..
Migraine headaches…………….
Ear trouble………………………..
Have you ever used tobacco
Claustrophobia, fear of enclosed
Difficulty hearing…………………
products? *………………………..
spaces…………………………….
Hearing aids……………………...
*On next page list type(s) used
Emotional/psychiatric disease….
and frequency of use of each.
Depression……………………….
Blood in urine…………………….
Also, list start and quit dates for
each product used.
Weakness in arms or legs………
Kidney trouble……………………
Other neurological problems…...
Urination difficulties……………..
HAVE YOU EVER HAD:
Yes
No
Bladder trouble…………………..
Back trouble or pain………..…...
Any other respiratory problems…
Back or neck injury………….…..
Liver trouble……………………...
Any hospitalizations/surgeries….
Back pain when lifting …………..
Hepatitis…………………………..
High blood pressure……………..
Shoulder surgery*……………….
Jaundice………………………….
Chest pain or pressure…………..
Gallbladder trouble………………
Back or neck surgery*…….…….
Heart attack………………………
Knee surgery*……………………
Diabetes or sugar in urine……...
Heart surgery…………………….
*On next page list any physical
Do you require insulin…………..
Swelling of ankles………………..
restrictions as a result of surgery
Have you ever passed out or
Swollen joints……….……………
Fainting/dizzy spells……………..
had an altered level of alertness
due to your diabetes…………...
Dislocated shoulder……………..
Varicose veins……………………
Needed the help of others for
Rheumatism or arthritis…………
Palpitations/skipped beats………
your diabetes…………………….
Fracture or broken bone……..…
Heart murmur………………….….
Thyroid trouble or goiter………...
Any other heart
Continued on next page
disease/condition or tests……….
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Revised: 04.06.11
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