<FORM action="..." method="post">
<P>
<FIELDSET>
<LEGEND>Personal Information</LEGEND>
Last Name: <INPUT name="personal_lastname" type="text" tabindex="1">
First Name: <INPUT name="personal_firstname" type="text" tabindex="2">
Address: <INPUT name="personal_address" type="text" tabindex="3">
...more personal information...
</FIELDSET>
<FIELDSET>
<LEGEND>Medical History</LEGEND>
<INPUT name="history_illness"
type="checkbox"
value="Smallpox" tabindex="20"> Smallpox
<INPUT name="history_illness"
type="checkbox"
value="Mumps" tabindex="21"> Mumps
<INPUT name="history_illness"
type="checkbox"
value="Dizziness" tabindex="22"> Dizziness
<INPUT name="history_illness"
type="checkbox"
value="Sneezing" tabindex="23"> Sneezing
...more medical history...
</FIELDSET>
<FIELDSET>
<LEGEND>Current Medication</LEGEND>
Are you currently taking any medication?
<INPUT name="medication_now"
type="radio"
value="Yes" tabindex="35">Yes
<INPUT name="medication_now"
type="radio"
value="No" tabindex="35">No
If you are currently taking medication, please indicate
it in the space below:
<TEXTAREA name="current_medication"
rows="20" cols="50"
tabindex="40">
</TEXTAREA>
</FIELDSET>
</FORM>