Create an interactive medical form in wordpress

Programming a single page for a website (on a Wordpress template). Please see the attached [login to view URL] with the walk-through of the coding requested. In essence I need a page where you click a body part (images provided) on the left side, which triggers three level list of sicknesses to appear in the centre of the page. The list expands and collapses according to the users selection. In the third level of the list each item has a corresponding number, which put into a hidden field on the right side of the page. No specific coding language required as long as it works inside a Wordpress template.