NAME___________________________________

PHONE__________________________________

E-MAIL__________________________________

HOST PLANT______________VARIETY___________
DATE COLLECTED________________________

(Completely dead or dry plant material is of no value)

APPROXIMATE AGE OF PLANT______________

LENGTH OF TIME IN PRESENT LOCATION_________

WHEN DID SYMPTOMS OCCUR?_________________

WERE SYMPTOMS APPARENT IN PREVIOUS YEARS?________

BRIEFLY DESCRIBE THE PROBLEM:

CHEMICALS/FERTILIZERS APPLIED & DATED APPLIED (Including nearby lawn)

  PLANT PART(S) SHOWING SYMPTOMS:

            ___LEAVES/NEEDLES            ___FRUIT

           ___STEM/TRUNK                    ___FLOWERS

           ___BRANCHES                         ___ROOTS/TUBERS

           ___BUDS

SYMPTOMS (Examine ALL plant parts):

             ___WILT                                     ___ABNORMAL COLOR

             ___ROT                                       ___ABNORMAL GROWTH

             ___STEM CANKER                   ___FUNGUS-LIKE GROWTH

             ___LEAF SPOTS, SCABS           ___INSECTS

             ___DEAD AREAS

DEGREE OF DAMAGE:

          ___HEAVY                                   ___LIGHT

          ___MEDIUM                                ___% OF PLANT AFFECTED

PRUNING HISTORY____________________________

              (Have any major branches died and been removed?)

ARE ANY NEIGHBORING PLANTS AFFECTED? _____________________

WEATHER CONDITIONS (past 4-5 years) ____________

CONSTRUCTION/OR OTHER DISTURBANCES (in past 4-years)____________________

EXPOSURE: ___FULL SUN   ___FULL SHADE   ___PARTIAL SHADE

                       ___WINDY        ___PROTECTED

  MOISTURE/DRYING/IRRIGATION:
          ___OVERHEAD          ___HAND                   ___DRIP/TRICKLE

FREQUENCY: (times per week) ______________

LOCATION:

          ___LANDSCAPE

          ___FLOWER/VEGETABLE GARDEN

          ___NEAR SIDEWALK/DRIVEWAY/STREET

SOIL CONDITIONS- DRAINAGE:

          ___GOOD      ___MODERATE     ___POOR

TERRAIN:              ___SLOPED   ___LEVEL    ___LOW