Endocrine Providers:
Address:
Dr. Vishal Datta,
356 Mill Street
Ashley DeLuca, PA
Hagerstown, MD 21740
Phone: (301)-733-1031
Fax: (301)-733-3041
E-mail: info@dattaendocrinewellnees.com
Website: www.dattaendocrinewellness.com
WELCOME TO OUR OFFICE!! Thank you for selecting our practice. In order to provide the best medical
care and a great experience when you visit us please read on. If you have any other questions, feel free
to call us at (301) 733-1031 or 301-733-1032.
************* WHAT TO BRING WITH YOU *************
-MEDICAL HISTORY FORM: (if included in this packet) Filling this out at home will give you time to
consider these questions instead of rushing to complete it while sitting in our office. DRIVER’S LICENSE
OR OTHER PICTURE ID This is to help prevent identity theft INSURANCE CARD AND COPAY The amount
of the copay is usually printed on your insurance card. You will need to pay your copay when you arrive
which you can pay with cash, check, or credit card.
-INSURANCE REFERRAL: If required, your primary care doctor will provide this to you. Check with your
insurance company. Without it your insurance may not pay for your visit.
- MEDICAL RECORDS: Your other doctors will provide this for you when you ask.
-X-RAY or SCANS: If you are seeing one of our Endocrinology Providers Dr Datta, or Physician Assistant
Ashley DeLuca, they will need to see these when you are here for your appointment. X-rays and scans
can usually be borrowed from the radiology department where they were performed.
-PRESCRIPTIONS: Bring the prescription bottles so your doctor knows exactly what you are currently
taking and the dosage.
*********** HELPFUL TIPS FROM OUR OFFICE ***********
RUNNING LATE? - We understand that circumstances can sometimes prevent you from arriving on
time. If this happens, we will try our very best to accommodate you within the schedule. If we are
unable to see you or you cannot wait, we will be happy to reschedule your appointment.
CANCELLATION- If you need to cancel or reschedule an appointment please call our office at least 24
hours before your appointment. Broken appointments represent a cost to us, and to other patients who
could have been seen in the time set aside for you. We reserve the right to charge for missed or latecanceled appointments.


If you are a follow-up patient, and do not show up for your appointment and fail to cancel
within 24 hours of your appointment, you will be charged a $25.00 no show fee.
If you are new patient, and do not show up for your appointment and fail to cancel within 24
hours of your appointment, you will be charged a $50.00 no show fee
Excessive abuse of scheduled appointments may result in discharge from the practice.
PAYMENT- If you have any questions about what insurances we accept, or about payment of your
deductible or copay please call our billing office at 301-733-1031 or 301-733-1032.
PRESCRIPTION REFILLS- If you need to refill your medication that we have prescribed, call your
pharmacy. They will contact us for you to obtain the refill authorization. Please note that once we
contact your pharmacy for a prescription request, it could take up to 24 hours for the prescription to be
filled by your pharmacy.
HOURS- Our office is open Monday through Friday from 8:00 am to 4:30 pm. You can reach us by phone
between 9 am and 4 pm. Our phones are off between 12:30 pm and 1 pm so our operators can take
lunch. ANY OTHER QUESTIONS, CALL (301) 733-1031 or 301-733-1032.
ANY OTHER QUESTIONS, CALL (301) 733-1031
PATIENT INFORMATION FORM
First Name: ____________________ Middle Name: ___________ Last Name: _________________
Date of Birth: _____________ Sex: Male or Female? Marital Status (Select): Single, Married, Other
Social Security Number_______________________
Referring Physician Name: ___________________________________________
Patient Address:
Street: ____________________________________ City: ______________________ State: __________
Zip Code: _________________ E-mail:_____________________________________________________
Home Phone: _____________________________Cell Phone: ______________________________
Preferred method of contact for appointment reminders (Please circle): Text to mobile, E-mail, Phone
call to home number or phone call to mobile phone
Preferred Pharmacy (Name, Address):
________________________________________________________________________________
Race: ____________________________ Name of Employer: _________________________________
Name of School: _____________________________________
Language Preference: _________________ Any Communication Barriers? _____________________
PATIENT’S INSURANCE INFORMATION
Primary Insurance Company Name: _______________________________________________
Subscriber’s Name: ____________________________________________________________
Subscribers Date of Birth: ___________________________________
Subscriber’s Social Security Number: ____________________________________
Insurance Company’s Address: ___________________________________________________
Co-Pay Amount: _______________
Policy Number: ___________________________ Group Number: ______________________
Secondary Insurance Company’s Name: ___________________________________________
Subscriber’s Name: ____________________________________________________________
Subscriber’s Date of Birth: _____________________________
Subscriber’s Social Security Number: ____________________________________
Insurance Company’s Address: ___________________________________________________
Co-Pay Amount: _______________
Policy Number: ___________________________ Group Number: ________________________
Next of Kin: _______________________________________________
Next of Kin’s Phone Number: ___________________________________
Next of Kin’s Address: _________________________________________________________
Name of Emergency Contact: _____________________________________________________
Emergency Contact’s Phone number: _______________________________________________
I AUTHORIZE THE ABOVE MEDICAL PRACTICE TO RELEASE ANY MEDICAL INFORMATION NECESSARY TO
PROCESS MY CLAIMS. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL FEES FROM
SERVICES PROVIDED, INCLUDING THE BALANCE REMAINING AFTER PAYMENT OF POSSIBLE INSURANCE
BENEFITS AND ANY COSTS INCURRED BY THE PHYSICIAN(S) IN ORDER TO COLLECT SUCH FEES.
SIGNED: ___________________________________________________________
PATIENT (OR PARENT’S SIGNATURE IF PATIENT IS A MINOR)
DATE: _______________________
Name: ______________________________________ Date of Birth_______________________
A. PERSONAL INFORMATION
Name:
Date of Birth:
Referring Physician:
Other Physicians:
Occupation:
Gender: M / F
Marital Status:
Today’s Date:
M
D
S
B. REASON FOR CONSULTATION
Please indicate the reason for your visit or your concerns or questions:
1._________________________________________________________________________________
2._________________________________________________________________________________
Name: ______________________________________ Date of Birth_______________________
C. GENERAL MEDICAL INFORMATION-Check Off the information that applies
CONDITION
YES
Runs in
Family
CONDITION
High Blood Pressure:
Liver Disorder
High Cholesterol:
Gall Bladder Disorder
High Triglycerides:
Diverticulitis
Diabetes Mellitus:
Heart Attack:
Other Abnormal Intestinal
Disorders
Kidney Stones
Angina/Coronary Disorder:
Urinary Infection
Other Heart Disorders:
Other Kidney/Bladder
Disorders
Stroke/TIA:
Arthritis
Seizures/Convulsions/Epilepsy:
Back Disorder
Migraine Headaches:
Neck Disorder
Other Neurological Disorders:
Menstrual Irregularities
Emphysema/Bronchitis:
Gout
Pneumonia:
Anemia
Asthma:
Cancer
Peptic Ulcer Disease:
Phlebitis (Inflamed Leg Veins)
Diabetic Ulcers
Non-Healing Ulcers
Increased Pain while exercising or
fast walking
Discoloration of legs or Pain in lower
legs
Other Lung Disorders:
Low foot pulses
Reflux Esophagitis/Hiatal Hernia:
Prostate Problems
Overweight/Obesity:
Glaucoma
Sleep Apnea:
Other Eye Disorders
Allergic Disorders:
Rashes or Other Skin
Disorders
Neuropathy
Breast Problems
Please give any details of any conditions are marked “Yes”
YES
Runs in
Family
Which family
member?
Name: ______________________________________ Date of Birth_______________________
D. MEDICATONS: List current Medications and dosages. Please include over the
counter medications, vitamins and other supplements.
Medication:
Dosage:
Frequency:
E. PAST SURGERIES (Please mention all major and minor
procedures).
Type of Surgery
Check if Yes
Thyroid Surgery
C-section
Amputation Surgery
Hernia Surgery
Stents
Joint Surgery
Hysterectomy
Aphrectomy-Balloon Surgery
Other:
Other:
Other:
Other:
Name: ______________________________________ Date of Birth_______________________
F. Leg or Foot Discomfort
Symptoms
Check if Yes
Fatigue in leg muscles (buttocks, thigh or calf
that occurs during activities such as walking
or climbing stairs).
Pain in legs or feet that disturbs sleep/or rest
Numbness, tingling, coldness in lower legs or
feet
Wounds or Sores on feet or legs that are slow
to heal
Color changes in the or feet or toes (i.e.
blueness, paleness, or discolored)
Have you ever been told that you have weak
or absent pulses in your feet?
G. ALLERGIES:
Do you have any allergies to any medication(s)? ______________________________________
Do you have allergies to X-ray dye? _________________________________________________
Do you have any allergies to food? _________________________________________________
H. SOCIAL HISTORY:
( ) Current Smoker: How many packs a day? _____
( ) Former Smoker: How Many years ago? ______
( ) Drink Alcohol: How many drinks per week? ______
( ) Do you exercise on a regular basis? Y/N, if Yes, What type of activity and how often?
_____________________________________________________________
( ) Ionizing radiation exposure to head or neck? _______
( ) Excessive intake of Iodine-containing food (i.e. shell fish)? _______________________
Name: ______________________________________ Date of Birth_______________________
I. RECENT SYMPTOM LIST: Have you had problems with any of the following?
General:
( ) fatigue ( ) unintentional weight loss ( ) weight gain ( ) fever ( ) chills ( ) excessive sweating
( ) excessive thirst ( ) feeling excessively cold ( ) feeling excessively hot ( ) increase in appetite
( ) decrease in appetite ( ) change in ring size ( ) change in shoe size
Neurological & Psychological:
( ) depressed mood ( ) anxiety attacks ( ) excessive nervousness ( ) irritability
( ) black out spells or loss of consciousness ( ) dizziness ( ) forgetfulness
( ) difficulty concentrating ( ) headaches ( ) poor sleep ( ) sleep too much ( ) numbness or
tingling in the hands or feet ( ) tremors ( ) seizures
Head/Neck:
( ) visible lump in the front of the neck ( ) trouble swallowing ( ) pain swallowing ( ) persistent
hoarseness ( ) voice change ( ) neck pain ( ) sinus problems ( ) dry mouth ( ) sore throat
( ) swollen glands in neck ( ) neck fullness ( ) choking sensation ( ) pressure in neck ( ) dizziness
Eyes:
( ) bulging eyes ( ) dry eyes ( ) eye irritation ( ) double vision ( ) tunnel vision ( ) blurred vision
( ) loss of vision ( ) loss of peripheral vision
Skin:
( ) dry skin ( ) itching ( ) dry or brittle hair ( ) hair loss or balding ( ) weak or cracking nails
( ) easy bruising or bleeding ( ) yellowish skin ( ) rash ( ) increased hair growth on the ( ) face
( ) chest ( ) breast ( ) abdomen
Heart/Lung:
( ) palpitations ( ) swelling in feet or ankles ( ) chest pain ( ) shortness of breath ( ) cough
( ) wheezing
Gastro:
( ) diarrhea ( ) constipation ( ) frequent bowel movements ( ) abdominal pain ( ) nausea
( ) vomiting ( ) heartburn ( ) change in bowel movements
Muscles/Joints: ( ) muscle weakness ( ) muscle aches and pains ( ) swollen joints ( ) joint aches ( ) joint stiffness
G/U:
( ) difficulty urinating ( ) excessive urinations ( ) getting up to urinate at night
WOMEN ONLY:
Pre-menopause: ( ) infrequent menses ( ) no menstrual cycle ( ) heavy menses ( ) light menses ( ) hot flashes
( ) low sexual desire ( ) irregular menstrual cycle ( ) change in menstrual cycle
How old were you when you first started your menstrual cycle? _______________________________________
What was the last day of your menstrual cycle? ____________________________________________________
What method of contraception (if any) are you currently using? _______________________________________
Post menopause: ( ) hot flashes ( ) low sexual desire ( ) vaginal dryness
Breasts:
( ) breast tenderness ( ) fluid leakage from breast/(s) ( ) breast lump
MEN ONLY:
( ) impotence ( ) low sexual desire ( ) difficulty with erections ( ) prostate problems ( ) testicular lumps
( ) pain in testicles
PLEASE COMPLETE THIS FORM ONLY OF YOU HAVE PRE-DIABETES/DIABETES
Name (First, MI, Last)
Date:
Date of Birth:
In what year were you diagnosed with Diabetes? How old were you?
Have you ever had any Diabetes related complications? (Please check off the symptoms)
__ High Blood Pressure
__ Diabetic Eye disease or previous laser treatment
__ High cholesterol
__ Nerve problems (numbness/tingling)
__ Heart attack or chest pain/pressure while walking
__ Kidney problems or protein in your urine
__ Stroke or TIA
__ Dental problems or Gum disease
__ Pain/Cramps in lower legs while walking
__ Depression
__ Erectile dysfunction
Have you ever been hospitalized for uncontrolled blood sugar? Y or N (circle)
If yes, When and where?
What insulin and other medications (names of medication/ dosages/frequency) do you take for
Diabetes?
Do you check your blood sugars at home? (Please always bring you meter with you to your
appointments)
During the past month, what have you sugar readings been?
Fasting/pre-breakfast sugars:
Highest:
Lowest:
Average:
Pre-lunch sugars:
Highest:
Lowest:
Average:
Pre-dinner sugars:
Highest:
Lowest:
Average:
Bedtime sugars:
Highest:
Lowest:
Average:
What year did you get your last pneumonia vaccination? **If you have not had a pneumonia
vaccination: The Centers for Disease Control (CDC) recommends that all people with diabetes receive
a pneumonia vaccination to reduce your chance of getting a bacterial pneumonia infection. It protects
against 23 types of pneumococcal bacteria. It is recommended once before the age of 65 and once
after the age of 65 but not within 5 years of a previous pneumonia vaccination.
Have you had a flu shot during this flu season (between October and February)? **If you have not
had a flu shot: A yearly flu shot is recommended to people with Diabetes.
When was your last eye exam? **It is recommended that all people with diabetes have a yearly eye
exam.
Please remember to bring your blood sugar meter and blood sugar record to your appointment. For the
week prior to your visit, we request that you check your sugars 4 times a day (before each meal and
bedtime) and bring these numbers written down to your appointment. Please bring all of your
medication bottles with you to your visit.