document.write('
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  1. <!DOCTYPE html>
  2. <html lang="en">
  3. <head>
  4.     <meta charset="UTF-8">
  5.     <title>Checkbox</title>
  6. </head>
  7. <body>
  8.     <p>Penyakit yang diderita :</p>
  9.     <form action="">
  10.         <p>Nama depan : <input type="text" name="fname"></p>
  11.         <p>Nama belakang : <input type="text" name="lname"></p>
  12.         <input type="Checkbox" name="Checkbox1" >Darah tinggi </input><br>
  13.         <input type="Checkbox" name="Checkbox1" >Asam urat </input><br>
  14.         <input type="Checkbox" name="Checkbox1" >Maag </input><br>
  15.         <p><input type="image" src="image/Untitled-2.png" alt="submit"></p>
  16.     </form>
  17. </body>
  18. </html>
');