1. Adobe Acrobat let's you make fillable pdf's that your patients can download and fill in using Adobe Reader. Most people have a pdf-reader on their PC.
2. You can make a MS Word form with the right fields on the right place and use the scanned jpg as a watermark or background. But there are less people with MS Word or an equivalent program than there are with Adobe Reader.
3. You can make a html-form that people can fill in in their browser and have a button on it to store the contents in the database behind your website. More or less like the form you used to enter your question.