The report required by sections 26:4-38 and 26:4-39 of this title shall contain the following information:
a. Name, address, color, sex, nationality, and the age as nearly as practicable, of the person so infected with a venereal disease;
b. Character of the disease;
c. Probable source of infection; and
d. Whether the case has been previously reported or not; and if it has been reported, when, where, and by whom it was reported.