Meridian General
· Health Records
FORM MG-100 · DRAFT
Patient intake chart
Practice form for entering a patient record. Connected securely with Python Flask backend via Nginx.
Patient name
Date of birth
MRN
Encounter date
01
Patient
02
Vitals
03
History
04
Visit notes
05
Review & save
Patient details
Section 01 of 05
Sex assigned at birth
Select…
Female
Male
Intersex
Prefer not to say
Phone
*
Home address
Emergency contact name
Emergency contact phone
Insurance provider
Policy / health card no.
Continue to vitals
Vitals
Section 02 of 05
Height (cm)
Weight (kg)
Blood pressure
Heart rate (bpm)
Temperature (°C)
Oxygen saturation (%)
Back
Continue to history
Medical history
Section 03 of 05
Known allergies
Penicillin
Latex
Peanuts
Shellfish
Contrast dye
None known
Current medications
Pre-existing conditions
Family history of note
Back
Continue to visit notes
Visit notes
Section 04 of 05
Reason for visit
*
Attending clinician
Assessment
Plan / follow-up
Back
Continue to review
Review & save
Section 05 of 05
Back
Save record