Widdoes St., Brgy.

II, City of San Fernando,

La Union

School of Health Sciences

Performance Checklist
Breast Self Examination / Testicular Self Examination

Name: __________________________________________Date: ________________________

Subject: _______________________________Instructor:_____________________________

Breast Self Examination

Inspection before a mirror 5 4 3 2 1

1. Stand and face the mirror with your arm relaxed at your sides or hands
resting on the hips, then look for any change in size or shape, lumps or
thickenings, any rashes or other skin irritation, dimpled or puckered skin,
any discharge or change in the nipples.

2. Turn to the right and the left for a side view look for any flattening.

3. Bend forward from the waist with arms raised over the head.

4. Stand straight with the arms raised over the head and moved the arms
slowly up and down at the sides (look for free movement of the breast
over the chest wall).

5. Press your hands firmly together at chin level while the elbows are raised
to the shoulders.

Palpation: Lying position 5 4 3 2 1

1. Place a pillow under your right shoulder and place your right hand under
your head. This position distributes breast tissue more evenly on the chest.

2. Use the finger pads or tips of the three middle fingers held together on
your left hand to fell for lumps.

3. Press the breast tissue against the chest wall firmly enough to know how
your breast feels. A ridge of firm tissue in the lower curve of each breast
is normal.
 4. Use small circular motions symmetrically all the way around the breast as
many times as necessary until the entire breast is covered

5. Bring your arm down to your side and feel under your armpit, where
breast tissue is also located.

6. Repeat the exam on your left breast, using the finger pads of your right
hand.

Testicular Self Examination

Procedure 5 4 3 2 1

1. Choose one day of each month (e.g.., first or last day of each month) to
examine yourself.

2. Examine yourself when you are taking a warm shower or bath.

3. Support the testicle underneath with one hand. Place the fingers of the
other hand under the testicles and the thumb on top (this may be easier to
do if the leg on that side is raised.

4. Roll each testicle between the thumb and fingers of your hand, feeling for
lumps, thickening in consistency. The testes should feel smooth.

5. Palpate the epididymis, a cordlike structure on the top and back of the
testicle.

6. Using a mirror, inspect your testicles for swelling, any enlargement, or

lumps in the skin of the testicle.

7. Report any lumps or other changes to your health care provider promptly.

Legend:
5 - Excellent 2 - Fair
4 - Very Good 1 - Needs Improvement
3 - Good

CLINICAL INSTRUCTOR’S COMMENTS:

____________________________ ___________________________
Student’s Signature Clinical Instructor’s Signature