Medical History Questionnaire Form - Municipal Fire And Police Retirement System Of Iowa Page 3
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3Municipal Fire and Police Retirement System of Iowa
Medical History Questionnaire
NAME: __________________________________________
SSN: ___________________________
Applicant’s Declaration and Notice Regarding Pre-existing Medical Conditions
I understand that this physical examination is for job placement purposes or is required by my
employer and is not a complete physical exam. I understand that I should see my personal
physician if I wish to receive a complete physical exam. The information I have provided is true
and correct to the best of my knowledge. I understand that failure to truthfully complete this form
may result in my termination, disciplinary action, and/or denial of disability benefits for a condition
not identified.
I understand that Iowa Code section 411.6 provides that I will not be eligible for a disability pension
from the fire and police retirement system for a medical condition that would not exist absent a
medical condition that was known to exist on the date my membership commenced. I hereby
acknowledge that any medical condition identified in any manner during this medical examination
process is known by me to exist at the time my membership in the retirement system commences.
I further certify that I have completed this form accurately and completely.
Signature: _______________________________________
Date: ____________________
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Revised: 04 06 11
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