Transcription of MODIFIED - GLOBAL ASSESSMENT OF FUNCTIONING Scale …
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MODIFIED - GLOBAL ASSESSMENT OF FUNCTIONING Scale …
Page 1 of 2 MODIFIED GLOBAL ASSESSMENT of FUNCTIONING Revised (mGAF-R) Name of person being evaluated Optiona required only i needed by your agency or copy is retained in paper clinical record, please prin ): (l:ft (last)_____(first)_____(mi)__ SSN of person being Evaluated: (Required) :___ ___ ___/___ ___/ ___ ___ ___ ___ Date of Birth (Required) : _____/_____/_____ mm dd yyyy Provider Agency Tax ID (Requ red): _____i Gender: (Required) Male Female Date of ASSESSMENT (Required): _____/_____/_____ mm dd yyyy Use the Criteria below to determine the individual s current functional status, then enter rating on back of this form.
Page 1 of 2 Modified Global Assessment of Functioning – Revised (mGAF-R) Name of person being evaluated Optiona required only i needed by your agency or copy is retained in paper
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