Action needed: Fill Out Post Stem Cell Evaluation

Post-Treatment Evaluation

Please complete this form to share feedback on your child’s progress following their stem cell treatment.
Demographics & Treatment Information
Today's Date
Date of Treatment
Child's name
Date of birth (child)
Parent/Guardian Name(s):
Medications started AFTER stem cell therapy (if any):
Therapies started AFTER stem cell therapy (if any):
Post-Procedure Responses
1/9. Communication Skills
Describe communication BEFORE and AFTER stem cell therapy

Rows	None	Limited	Moderate	Strong	Consistent
Eye contact BEFORE
Eye contact AFTER
Response to name BEFORE
Response to name AFTER
Verbal language BEFORE
Verbal language AFTER
Non-verbal communication BEFORE
Non-verbal communication AFTER
Ability to follow commands BEFORE
Ability to follow commands AFTER

Please describe the communication changes you observed since therapy (positive and/or negative):
2/9. Social Interaction Skills
Describe social skills BEFORE AND AFTER stem cell therapy

Rows	None	Limited	Moderate	Strong	Consistent
Interest in people BEFORE
Interest in people AFTER
Initiates interaction BEFORE
Initiates interaction AFTER
Joint attention BEFORE
Joint attention AFTER
Emotional reciprocity BEFORE
Emotional reciprocity AFTER
Play skills BEFORE
Play skills AFTER
Awareness of others BEFORE
Awareness of others AFTER

Please describe the social changes you observed since therapy (positive and/or negative):
3/9. Behavior & Sensory Skills
Describe the behavior and sensory skills BEFORE and AFTER stem cell therapy

Rows	None	Limited	Moderate	Strong	Consistent
Repetitive behaviors BEFORE
Repetitive behaviors AFTER
Meltdowns/tantrums BEFORE
Meltdowns/tantrums AFTER
Hyperactivity BEFORE
Hyperactivity AFTER
Aggression/self-injury BEFORE
Aggression/self-injury AFTER
Anxiety BEFORE
Anxiety AFTER
Sensory sensitivities BEFORE
Sensory sensitivities AFTER
Rigidity/resistance to change BEFORE
Rigidity/resistance to change AFTER

Please describe the behavioral or sensory changes you observed since therapy (positive and/or negative):
4/9. Functional Skills
Describe the functional skills BEFORE and AFTER stem cell therapy

Rows	None	Limited	Moderate	Strong	Consistent
Sleep quality BEFORE
Sleep quality AFTER
Eating/feeding BEFORE
Eating/feeding AFTER
Toileting BEFORE
Toileting AFTER
Independence BEFORE
Independence AFTER
Safety awareness BEFORE
Safety awareness AFTER
Transitions between activities BEFORE
Transitions between activities AFTER

Please describe the functional changes you observed since therapy (positive and/or negative):
5/9. Cognitive & Learning Skills
Describe the cognitive & learning skills BEFORE and AFTER stem cell therapy

Rows	None	Limited	Moderate	Strong	Consistent
Attention span BEFORE
Attention span AFTER
Learning ability BEFORE
Learning ability AFTER
Problem solving BEFORE
Problem solving AFTER
Memory BEFORE
Memory AFTER
School participation BEFORE
School participation AFTER
Ability to follow routines BEFORE
Ability to follow routines AFTER

Please describe the cognitive and learning changes you observed since therapy (positive and/or negative):
6/9. Language Development Skills
Describe the Language Development Skills BEFORE and AFTER stem cell therapy

Rows	None	Limited	Moderate	Strong	Consistent
Vocabulary BEFORE
Sentence formation BEFORE
Understanding language BEFORE
Expressing needs BEFORE
Conversational ability BEFORE
Vocabulary AFTER
Sentence formation AFTER
Understanding language AFTER
Expressing needs AFTER
Conversational ability AFTER

Please describe the language changes you observed since therapy (positive and/or negative):
7/9. Quality of Life Skills
Describe the Quality of Life Skills BEFORE and AFTER stem cell therapy

Rows	None	Limited	Moderate	Strong	Consistent
Happiness BEFORE
Happiness AFTER
Participation in activities BEFORE
Participation in activities AFTER
Social engagement BEFORE
Social engagement AFTER
School readiness BEFORE
School readiness AFTER
Family stress level BEFORE
Family stress level AFTER
Overall functioning BEFORE
Overall functioning AFTER

Please describe the quality of life changes you observed since therapy (positive and/or negative):
8/9. Medical & Physical Skills
Describe the Medical & Physical Skills BEFORE and AFTER stem cell therapy

Please describe the medical/physical changes you observed since therapy (positive and/or negative):
9/9.

In your opinion, what have been the most impactful changes (positive, negative) since the stem cell therapy?
Please provide specific examples:
Parent's signature
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Post-Treatment Evaluation