SENSORY EVALUATION LABORATORY FOOD AND NUTRITION RESEARCH INSTITUTE

Document Code:

Screening Questionnaire Revision Page ___ of ____ Effectivity Date: Jan. 2015

We are recruiting panelists/assessors for sensory evaluation of the products being developed at the

Food and Nutrition Research Institute. We would like to match your product preferences, usage and

sensory skills to these products. Please accomplish this questionnaire and indicate your answers by

putting a check (√) in appropriate boxes. All information will be maintained confidential.

Name

Last First Middle

Birthdate (mm/dd/yy)

Gender Male Female

Status Single Married, __ no. of children

Address

Street No./Name Town/Municipality City/Province

Contact Details

Telephone/ Mobile No Office/Business No. e-mail address

1. Please indicate which, if any, of the following foods disagree with you (allergy, discomfort,

religious belief, customs and traditions, others)

Cheese (specify) ____________ Poultry _____________________

Chocolate _________________ Seafood ____________________

Eggs _____________________ Beans, Nuts _________________

Fruits (specify) ______________ Spices (specify) ______________

Meats (specify)______________ Vegetables (specify) __________

Milk ______________________ Others (specify) _____________

2. Please indicate if you are on a special diet

Diabetic ________________ Low salt ________________________

High Calorie _____________ Low Calorie _____________________

No special diet ____________ Others (specify) __________________

3. Do you smoke? Yes, how much do you smoke in a day

Never

Used to be a smoker but have quitted smoking

When did you quit smoking? _________________

4. Do you go on field work? Yes No

If yes, how often? ____________________________

how long? ____________________________

5. Are you interested and willing to become one of our sensory panelists? Yes No

Signature ______________________ Date __________________________