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 __________________________