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<body>
<form action="deneme.php" method="POST">
<fieldset>
<legend>Kişisel Bilgiler</legend><br/>
Adı: <input name="personal_fname" type="text" size="20" tabindex="1"/>
Soyadı: <input name="personal_lname" type="text" size="25" tabindex="2"/><br/><br/>
Adresi: <input name="personal_address" type="text" size="55" tabindex="3"/><br/><br/>
<!-- ...diğer kişisel bilgiler... -->
</fieldset>
<fieldset>
<legend>Tıbbî Geçmişi</legend><br/>
<input name="gecirilen_hastalik"
type="checkbox"
value="bogmaca" tabindex="20"/> Boğmaca
<input name="gecirilen_hastalik"
type="checkbox"
value="kabakulak" tabindex="21"/> Kabakulak
<input name="gecirilen_hastalik"
type="checkbox"
value="kizamik" tabindex="22"/> Kızamık
<input name="gecirilen_hastalik"
type="checkbox"
value="sucicegi" tabindex="23"/> Suçiçeği<br/><br/>
<!-- ...tıbbi geçmişi ile ilgili diğer... -->
</fieldset>
<fieldset>
<legend>İlaç Tedavisi</legend><br/>
Halen kullanmakta olduğunuz ilaçlar var mı?<br/>
<input name="medication_now"
type="radio"
value="Evet" tabindex="35"/> Evet
<input name="medication_now"
type="radio"
value="Hayir" tabindex="35"/>Hayır<br/><br/>
Eğer ilaç kullanıyorsanız, aşağıya kullandığınız ilaçları ve
günlük dozlarını belirtiniz:<br/>
<textarea name="kullandigi_ilaclar"
rows="10" cols="60"
tabindex="40">
</textarea>
</fieldset>
<input type="submit" value="Yolla">
</form>
</body>
</html>
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