Basically the client wants the email they receive to look like the original form, you do not need to change the actual form([url removed, login to view]) itself this is just the email that is sent out needs to be formatted the same as the template(Health History [url removed, login to view]) I've attached.
[url removed, login to view] is the form, and it's uses HTML arrays - You need to be familiar with that.
Health History [url removed, login to view] is the template file, the email should look very similar to this.
probably a Smarty approach would be the best
You don't have to worry about sending HTML email. You must only layout the $_POST datas into the template file.