Name ___________________________________________________ Phone # _______________

Address ___________________________________________________________________________

City ___________________________ State ___________ Zip ___________________

Instruction: Fill out as completely as possible the following questionnaire. This is to aid in diagnosing the problem your tree or shrub is experiencing.

Plant Name: ______________________________ Variety/Cultivar: __________________________

Brief description of problem (off color of foliage, chewed foliage, etc.)? _____________________________

_________________________________________________________________________________________

Size of plant? Height?________ Width?________ Age of plant, if known?______________________

When was the problem noticed? ________________________________________________________

What part of the tree or shrub is affected (all, 1 limb, etc.)___________________________________

Has the problem occurred before? __________ When? _____________________________________

Are similar plants nearby?____________ How near?_______________________________________

Are they affected?__________ Is the plant a recent transplant? ______________________________

When? ___________________________________________________________________________

Was it balled and burlapped?_________ container?_________ bare root?______________________

Other? ___________________________________________________________________________

Was the burlap or container removed at planting time? _____________________________________

Was fertilizer used? ______________ How much?(lbs/100 sq ft) _____________________________

What kind (5-10-5, etc.?) _____________________________________________________________

Is the plant near a foundation, pool or other structure? _____________________________________

What kind of structure? ________________ Is the plant watered? ____________________________

How (sprinkler, hose, watering can, etc.)? _______________________________________________

How often (once a week, etc.)? ___________ How much water (approx.)? ______________________

Is the site sunny? _______ shady? __________ Hours of direct sun? __________________________

Is the site windy? ________

Is the plant located near a down spout or in a depression where water gathers? __________________

Were herbicides or weed and feed fertilizers used near or around the plant? ____________________

What kind? ________________ How much? _________________ When? _____________________

Did you notice damage on the trunk or branches? (bark removed by lawnmowers, cracks, holes, etc.)? ________________________________________________

Was any fertilizer applied?______________ When?___________

How much (lb/sq ft)? __________. Kind (5-10-10, etc.)? ___________________________________

Were wood ashes used around the plant(s)? _________ How much? __________________________

Was any insecticide and/or fungicide used? _________ When? ________ Kind? ________________

How was it applied (spray, dust to soil, etc.)? _____________________________________________

How often? ________________________________________________________________________

Is a road or driveway nearby? ______________ How close (ft.)? _____________________________

Deicing salts used? _________________________

Was the ground level lowered or raised recently, especially near trees?_________________________

When? _________________ How much (inches or ft.)? _____________________________________

Were any ditches or excavations made near the tree? _______________________________________

How close? _________________ How deep? _________________ When? _____________________

Are any mulches used around the plant? ________________ How thick? ______________________

What kind (plastic, sawdust, leaves, etc.)? ________________ How close? _____________________

In addition to the above information submit a sample of the "diseased" plant. Include in the sample both diseased and healthy tissue. Place the sample in a plastic bag and mail it in a STURDY box to your local extension office or the Home & Garden Education Center, 1380 Storrs Road, U-115, Storrs, CT, O6269-4115.

Date Received ________/________/________

Diagnosis ________________________________________________________

By whom ________________________________________________________

Recommendations ___________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Prepared by: Edmond L. Marrotte, Consumer Horticulturist, Department of Plant Science, Revised 6/98

This information was developed for conditions in the Northeast. Use in other geographical areas may be inappropriate.

The information in this material is for educational purposes. The recommendations contained are based on the best available knowledge at the time of printing. Any reference to commercial products, trade or brand names is for information only, and no endorsement or approval is intended. The Cooperative Extension system does not guarantee or warrant the standard of any product referenced or imply approval of the product to the exclusion of others which also may be available.All agrochemicals/pesticides listed are registered for suggested uses in accordance with federal and Connecticut state laws and regulations as of the date of printing. If the information does not agree with current labeling, follow the label instructions. The label is the law.Warning! Agrochemicals/pesticides are dangerous. Read and follow all instructions and safety precautions on labels. Carefully handle and store agrochemicals/pesticides in originally labeled containers immediately in a safe manner and place. Contact the Connecticut Department of Environmental Protection for current regulations.The user of this information assumes all risks for personal injury or property damage.Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture. Kirklyn M. Kerr, Director, Cooperative Extension System, The University of Connecticut, Storrs. The Connecticut Cooperative Extension System offers its programs to persons regardless of race, color, national origin, sex, age or disability and is an equal opportunity employer.