(a)__The pregnancy was a result of rape;

(b)__The pregnancy was a result of incest;

(c)__The mother cannot afford a child;

(d)__The mother does not desire to have a child;

(e)__The mother's emotional health is at stake;

(f)__The mother will suffer substantial and irreversible impairment of a major bodily function if the pregnancy continues; or

(g)__Other;

(6)__Whether each induced abortion was paid for by:

(a)__Private insurance;

(b)__A public health plan; or

(c)__Other;

(7)__Whether insurance coverage, if any, was by:

(a)__A fee-for-service insurance company;

(b)__A managed care insurance company; or

(c)__Other;

(8)__Complications, if any, of each abortion and of the aftermath of each abortion.__Space for complication descriptions must be available on the reporting form;

(9)__The fee collected for performing each abortion or treating each patient in connection with an abortion;

(10)__The type of anesthetic, if any, used for each induced abortion;

(11)__The method used to dispose of fetal tissue and remains;

(12)__The specialty area of the physician;