complex database design for many checkboxes

I'm currently creating a website for a local hospital. the problem, am currently facing the website has too many checkboxes and fields that are enabled/disabled depending on the checkbox

this is url to the website: http://ali.ezyro.com/adan/myForm.php

since I have a little experience with databases, what is the best way to design the database to hold the all the data of this document?