How to implement a fill in the blank in my form?

Hi. How do I implement this different options in my form?

Please x any of the following that are current conditions and p that are past conditions:

HEAD & NECK

__ Headaches / migraines     __ Vertigo     __ Ringing in ears  __ Hearing loss     __ Vision problems        __ Vision loss

CARDIOVASCULAR

__ High blood pressure     __ Low blood pressure     __ Heart attack     __ Stroke     __ Heart disease

__ Poor circulation     __ Phlebitis / varicose veins     __ Pacemaker     __ Hemophilia

__ Chronic congestive heart failure     __ Family history of cardiovascular problems

RESPIRATORY

__ Asthma     __ Shortness of breath     __ Chronic cough     __ Bronchitis     __ Emphysema     __ Sinusitis

__ Frequent colds     __ Smoker     __ Family history of respiratory difficulties

NERVOUS SYSTEM

__ Sensory loss / change     __ Numbness / tingling     __ Sciatica     __ Epilepsy     __ Seizures

__ Multiple Sclerosis

MUSCULOSKELETAL SYSTEM

__ Arthritis: __ Osteoarthritis. __ Rheumatoid arthritis  __ Family history of arthritis

__ Osteoporosis     __ Tendonitis     __ Bursitis     __ Jaw pain     __ Pins / plates / wires / artificial joint

Thank you.

Thank you for contacting us. I can see that you have already done it in your form:

Let us know if you need more help.

The user wants to distinguish current or past for each condition. What I have is just a multiple choice boxes. Is it possible to have two columns (current and past) of multiple choice check boxes?

Hi, we have a new field that you can try. It is called Fill in Blanks. Example:

If you preview it, it will look like this in the browser:

But, you can shorten the text fields by injecting this CSS code in your form: https://www.jotform.com/help/117-How-to-Inject-Custom-CSS-Codes

li[data-type=control_inline] .FITB-inptCont[data-blottype=textbox] input {

    width: 20px !Important;

}

Example:

Hope this helps.