<!DOCTYPE html>
<html>
<head>
	<title>Cek Kesehatan(Adji Nurdiman-XI RPL 2)</title>
</head>
<body>
	<p>Penyakit Yang Diderita:</p>
	<form>
		<p>Nama Depan :<input type="text" name="fnama"></p>
		<p>Nama Belakang :<input type="text" name="lnama"></p>
		<input type="checkbox" name="checkbox1">Darah Tinggi<br>
		<input type="checkbox" name="checkbox2">Asama Urat<br>
		<input type="checkbox" name="checkbox3">Maag<br>
		<p><input type="image" name="gambar" src="https://www.gambaranimasi.org/data/media/426/animasi-bergerak-tombol-0555.gif" alt="submit"></p>
	</form>
</body>
</html>