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  <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">
 </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
 </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="10" cols="40"
            tabindex="40">
  </TEXTAREA>
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