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