Initial History Intake Form

Resources to Help You Learn More About NeurosciencesCenters

At Neurosciences Centers (NSC), we aim to offer the best possible care. To help us understand your medical history and personalize your treatment plan, please complete the Initial History Intake Form. This form will gather essential information about your symptoms, medical background, and pain management needs. Download the form below and bring it with you on your first visit to streamline your consultation.Ready to take the next step? Schedule your appointment now through our Healow Appointment Portal and begin your path to pain relief.

Patient Resources

Patients can find the following helpful resources

Epilepsy

Epilepsy is a chronic brain disorder that causes seizures, which are brief episodes of involuntary movement. Seizures occur when there’s an abnormal electrical discharge in the brain.

Symptoms

- Loss of consciousness or awareness
- Loss of control of bladder or bowel function
- Difficulty hearing or seeing
- Uncontrolled muscle movements
- Blank stare
- Temporary confusion
- Changes in taste, smell, vision, or hearing
- Feelings of numbness or tingling
- Psychic symptoms like fear, anxiety, or déjà vu

Causes

Imbalance of neurotransmitters, which are nerve-signaling chemicals
Tumors
Strokes
Brain damage from injury or illness
High or low blood sugar
Alcohol or drug withdrawal
Brain concussion

Treatment Anti-epileptic drugs, Brain surgery, Electrical devices implanted in the body, and Ketogenic diet.

Outlook

Epilepsy is a lifelong condition for most people
Most people with epilepsy can live normal lives if their seizures are well controlled
With proper diagnosis and treatment, an estimated 70% of people with epilepsy could be seizure free

Headaches

Headaches are a common neurological condition that can occur due to a number of possible reasons. A neurologist can help diagnose and treat headaches.

Types of headaches

Migraine: A throbbing pain that often affects one side of the head, and can cause nausea, vomiting, and sensitivity to light and sound
Tension headache: A constant “band-like” pressure on both sides of the head
Trigeminal neuralgia: Sudden attacks of severe facial pain
Occipital neuralgia: Pain that starts in the neck and spreads upward

When to seek medical advice Seek medical advice if you experience:

A headache that is severe or disrupts your daily life
A headache that worsens over 24 hours
A headache that occurs with a head injury
A headache that includes vision changes
A headache that occurs with other symptoms like balance loss, confusion, fever, or memory loss

Neurological tests

A neurologist may perform a physical exam, review your medical history, and order tests such as:

CT scan
MRI
EEG
Evoked potential (EP) tests
Electromyography (EMG)
Nerve conduction studies
Ultrasonic vascular studies

Diabetic neuropathy

Diabetic neuropathy is a complication of diabetes that damages the nerves, primarily in the feet, hands, legs, and arms.

Causes:

High blood sugar levels damage the blood vessels that nourish the nerves
Oxidative stress caused by high blood sugar damages the myelin sheath, the protective layer around the nerves.

Symptoms:

- Numbness, tingling, or burning sensations
- Pain, especially at night or when walking
- Weakness or muscle cramps
- Foot deformities
- Difficulty with balance and coordination
- Loss of sensation in the feet, making it susceptible to injuries

Types:

Peripheral neuropathy: Most common type, affecting the nerves in the feet and hands.
Autonomic neuropathy: Affects the nerves that control involuntary functions, such as digestion, urination, and heart rate.

Proximal neuropathy: Affects the nerves in the thighs and buttocks.

Diagnosis:

Physical exam, Blood tests to check blood sugar levels, Nerve conduction study (NCS), and Electromyography (EMG).

Treatment:

Blood sugar control: Maintaining stable blood sugar levels is crucial.
Medications: Nerve pain medications, such as antidepressants or anticonvulsants.
Foot care: Regular foot checks, proper footwear, and avoiding smoking.
Physical therapy: To improve balance, coordination, and strength.
Surgery: In severe cases, to correct foot deformities.

Stroke

A stroke, also known as a brain attack, occurs when blood flow to the brain is interrupted, causing brain cells to die.

Types:

Ischemic stroke:

The most common type, caused by a blood clot that blocks an artery in the brain
Hemorrhagic stroke:

Occurs when a blood vessel in the brain bursts, leading to bleeding in the brain.

Causes:

- High blood pressure
- Heart disease
- High cholesterol
- Diabetes
- Smoking
- Obesity
- Family history
- Age (risk increases with age)

Symptoms:

Symptoms can vary depending on the severity and location of the stroke, but may include:

Sudden numbness or weakness on one side of the body
Sudden confusion or difficulty speaking
Sudden difficulty seeing in one or both eyes
Sudden trouble walking
Sudden severe headache
Sudden loss of balance or coordination

Treatment:

Time is critical in treating a stroke. Seek emergency medical attention immediately if you experience any stroke symptoms. Treatment may include:

Medications to dissolve the clot (for ischemic stroke)
Surgery to repair a ruptured blood vessel (for hemorrhagic stroke)
Rehabilitation to help regain lost function

Prevention:

Control high blood pressure
Manage heart disease
Lower cholesterol levels
Quit smoking
Maintain a healthy weight
Exercise regularly
Eat a healthy diet

Brain Tumors Cancers

Brain tumors are cancerous growths that can affect the brain and surrounding tissues. They can be malignant (cancerous) or benign (noncancerous).

Malignant brain tumors

- Medulloblastoma: The most common malignant brain tumor in children, usually affecting those between the ages of 5 and 9
- Olfactory neuroblastoma: A rare malignant tumor that develops in the nose
- Chondrosarcoma: A malignant bone cancer that mainly affects cartilage, usually developing in patients between the ages of 50 and 70
- Glioblastoma: A common malignant brain tumor
- Astrocytoma: A common malignant brain tumor
- Oligodendroglioma: A common malignant brain tumor
- Mixed gliomas: A common malignant brain tumor Metastatic brain tumors

Metastatic brain tumors

These tumors originate as cancer elsewhere in the body and then spread to the brain
Common cancers that can spread to the brain include breast, lung, and melanoma

Benign brain tumors

These tumors can grow but do not spread
Most tumors that happen in and around the pituitary gland are benign
Brain tumors can be treated with surgery, radiation, and chemotherapy.

Movement disorders

Movement disorders are neurological conditions that affect movement control, speed, and smoothness. They can involve too much movement, too little movement, or abnormal postures.

Types of movement disorders

Ataxia: Loss of muscle coordination that can lead to imbalance, clumsiness, and difficulty walking
Dystonia: Involuntary muscle contractions that can cause twisting and repetitive movements
Essential tremor: Involuntary rhythmic shaking, usually in the hands
Parkinson’s disease: Slowed movement, tremors, and imbalance caused by brain deterioration
Tourette syndrome: Sudden tics, movements, or sounds that can be uncontrollable
Chorea: Repetitive, brief, irregular, and involuntary movements that usually involve the face, mouth, trunk, and limbs

Causes

Brain injury, such as head trauma
Infection, inflammation, or metabolic disturbances
Toxins
Side effects of medications
Genetic disorders

Treatments

Medication, Physical therapy, Occupational therapy, Mobility aids, Speech therapy, Psychotherapy, Deep brain stimulation, and Clinical trials.

Memory disorders

Memory disorders are conditions that affect memory, thinking, and behavior. They can be caused by brain injury, disease, or other factors.

Common memory disorders

- Alzheimer’s disease: Affects memory, behavior, and brain function
- Dementia: A general term for a group of diseases that affect memory, thinking, and behavior
- Amnesia: Temporary or permanent loss of memory
- Delirium: A sudden change in thinking or behavior
- Transient global amnesia (TGA): A sudden, temporary loss of short-term memory
- Wernicke–Korsakoff syndrome: Causes confusion, amnesia, impaired short-term memory, and difficulty learning new information

Other memory disorders

Vascular dementia
Lewy body dementia
Frontotemporal dementias
supranuclear palsy
Creutzfeldt-Jakob disease (CJD)
HIV dementia

Some memory disorders can be treated, while others may permanently damage your ability to learn new things or retrieve memories.

Trigeminal neuralgia

Trigeminal neuralgia, also known as tic douloureux, is a chronic pain disorder that affects the trigeminal nerve, the main sensory nerve in the face.

Causes: The exact cause of trigeminal neuralgia is unknown, but it is believed to be related to a compression or irritation of the trigeminal nerve by a nearby blood vessel or other structure.

Symptoms: Trigeminal neuralgia typically causes sudden, severe, and excruciating pain on one side of the face. The pain is often described as: electric shock-like, stabbing, burning, and throbbing. The pain can be triggered by everyday activities such as brushing teeth, washing the face, or eating. It may also occur spontaneously.

Diagnosis: A doctor can diagnose trigeminal neuralgia based on a physical examination, medical history, and imaging tests such as an MRI or CT scan.

Treatment: Treatment for trigeminal neuralgia typically involves medication, such as anticonvulsants or pain relievers. Other treatments include:

Nerve blocks, Surgery, and Transcutaneous electrical nerve stimulation (TENS).

Prognosis: Trigeminal neuralgia is a chronic condition, but it can be managed with treatment. Most people with trigeminal neuralgia experience periods of remission between pain episodes.

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