(a) A physician performing an abortion upon an unemancipated minor shall provide the secretary a written report of the procedure within thirty days after having performed the abortion. The following information, in addition to any other information which may be required by the secretary, regarding an unemancipated minor receiving the abortion shall be included in the reporting form:
(2) Educational level;
(3) Previous pregnancies;
(4) Previous live births;
(5) Previous abortions;
(6) Complications, if any, of the abortion being reported;
(7) Reason for waiver of notification, if such notice was waived; and
(8) The city and county in which the abortion was performed.
(b) The report shall not contain the name, address or other information by which the unemancipated minor receiving the abortion may be identified.