Autism Progress Tracking Form

Education. Transparency. Patient-centered care.

Patient Information

Child's Name *

Date of Birth *

Parent / Guardian Name *

Email *

Date of Follow Up *

Timepoint *

1 Month

3 Months

6 Months

9 Months

Treatment Details

Therapy Received *

Mesenchymal Stem Cells + Exosomes

Dezawa Muse Cells + Muse Exosomes

Exosome Therapy Only

Date of Treatment *

Notes

Dose, route if known

Scoring Guide

0 = Not at all / No issue | 1 = Mild | 2 = Moderate | 3 = Significant / Severe

1. Communication

Subtotal: 0

Limited Eye Contact

Difficulty Expressing Needs

Limited Vocabulary / Speech

Difficulty Understanding Instructions

Delayed Response To Verbal Communication

Functional Communication Challenges

2. Social Interaction

Subtotal: 0

Limited Interaction With Parents

Limited Interaction With Others

Poor Engagement / Responsiveness

Lack Of Interest In Social Play

Inconsistent Response To Name

Reduced Joint Attention / Shared Attention

3. Behavior

Subtotal: 0

Repetitive Behaviors (Stimming)

Tantrums / Meltdowns

Hyperactivity

Short Attention Span

Aggressive Or Self-Injurious Behaviors

4. Sensory & Physical

Subtotal: 0

Sensitivity To Sound / Light / Touch

Food Selectivity

Sleep Difficulties

Low Or Irregular Energy Levels

Gastrointestinal Concerns (Constipation, Bloating, Etc.)

Total Score

👉 Lower scores over time = improvement

Parent Observations (Very Important)

What changes have you noticed since treatment? *

What improvements have been most meaningful? *

Any concerns or regressions? *

Medical & Therapy Updates

Any side effects or reactions? *

Any therapies started or continued (ABA, speech, OT, etc.)?

ABA Therapy

Speech Therapy

Occupational Therapy

Physical Therapy

Behavioral Therapy

Educational Support

Other

Parent Goals

What are your goals for the next phase? *

Optional: Would you be open to sharing your experience?

Yes

Stay Connected

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Would you like us to continue checking in and sharing updates with you?

Yes, please keep me subscribed

No, I prefer not to receive follow ups

Disclaimer

This form is intended for observational and functional tracking purposes only. It is not intended to diagnose, treat, cure, or guarantee clinical outcomes. Individual responses and progression may vary. All treatment decisions should be discussed directly with a licensed medical professional.

I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that this form is for observational tracking purposes.