Women’s Health In the Point Project (WHIPP)

Breast Self-Examination Survey

  • Please answer at least the first five Yes/No questions.
  • Other information is optional; however, we cannot reach you without contact information.
  • Your information is always kept confidential.
Do you know how to do a Breast Self-Examination (BSE)?*
YES NO

If YES, Do you do a monthly Breast Self- Examination (BSE)?

YES NO
Are you familiar with the suggested BSE technique?*
 YES NO
 
(this shows the three techniques of examination)
Have you had a breast examination by a doctor or nurse practitioner within the past two years?*
YES NO
Have you had a Mammogram within the past two years?* 
 YES NO
 

If not and if you are over 40 -
Is there a reason you have not had a Mammogram in the past two years?

 

Who is your doctor?
(Full name)

What is your doctor's hospital or clinic affiliation

  

What is your date of birth?

 Month Year
May we contact you to schedule a follow-up in six months to see how you’re doing?  
YES NO
 

Your Name:

 First Last
 

Your Address:

Street

Apt.
Zip code
  Phone: Home Other
 

Best times to call:
 

E-mail:

When you press Submit Survey, a screen appears confirming your information.
To return to the previous page, click the Back button on your browser

If you prefer to print this out, mail it to:

HERC - WHIPP
828 Innes Ave., Suite 110
San Francisco CA 94124

Telephone: (415) 401-6810