Answer all of the questions.  The comments sections are for therapists for any additional information.

Health Management

Medication set up na 0 1 2 3 4

Taking medication na 0 1 2 3 4

Obtaining supplies/food na 0 1 2 3 4

Personal Grooming

Dressing na 0 1 2 3 4

Hair care na 0 1 2 3 4

Nail care na 0 1 2 3 4

Oral care na 0 1 2 3 4

Meal/Laundry Preparation

Meal preparation - chop, slice, cut, peel foods na 0 1 2 3 4

Meal preparation - pour/measure ingredients na 0 1 2 3 4

Meal preparation - microwave na 0 1 2 3 4

Meal preparation - stove burners na 0 1 2 3 4

Meal preparation - oven na 0 1 2 3 4

Laundry preparation na 0 1 2 3 4

Financial Management

Manage records na 0 1 2 3 4

Accurately read bills/financial statements na 0 1 2 3 4

Write check/money order na 0 1 2 3 4

Using the Telephone

Physically operate telephone na 0 1 2 3 4

Retrieve telephone numbers na 0 1 2 3 4

Reading

TV guide on TV na 0 1 2 3 4

Books na 0 1 2 3 4

Labels/instructions na 0 1 2 3 4

Credit/debit cards na 0 1 2 3 4

Writing

Legible personal list/short note na 0 1 2 3 4

Legible address envelope na 0 1 2 3 4

Legible signature na 0 1 2 3 4

Functional Mobility

Ascend/descend stairs na 0 1 2 3 4

Adjusts to changes in walking surface na 0 1 2 3 4

Avoids collisions/tripping na 0 1 2 3 4

Locates and reads signs na 0 1 2 3 4

Personal Preference Activities

Shaving na 0 1 2 3 4

Leisure activities na 0 1 2 3 4

Operates devices used for leisure na 0 1 2 3 4

Read timepiece na 0 1 2 3 4

Shown here is the score for this assessment based on the answers from the previous tab.

Total NA questionsTotal uncalc'd pointsTotal adjusted pointsClients total pointsR-SRAFVP scoreImpairment %Medicare G-code Modifier

Scoring scale

This is the listing of possible question scores  and their meaning.

Medicare G Codes

This is the listing of possible Medicare G-Codes and their meaning.