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 __________________________