We are recruiting panelists 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.
Personal Information Last Name
First Name
Middle Name
Birthdate (mm/dd/yy)
Gender Male Female Status Single Married Section/ Division
Position Regular Contractual
Address/Contact Information Street No./Name
Town/Municipality
City/Province
Telephone/ Mobile No
Office/Business No.
E-mail address
1. Are you interested and willing to become one of our sensory panelists? Yes No 2. Are you pregnant? Yes No 3. 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) __________
Others (specify) ________ 5. 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? _________________ 6. Do you have dental problems? Yes ___________________ No 7. Do you go on field work? Yes No If yes, how often? ____________________________ how long? _____________________________ Signature: ____________________ Date: ____________________