Name
*
First Name
Last Name
What plant are we helping today?
*
How long have you had this plant?
*
Less than 1 month
1–6 months
6 months–1 year
More than 1 year
Have you repotted this plant recently?
*
Yes, within the last month
Yes, 1–6 months ago
Yes, more than 6 months ago
No, I’ve never repotted it
Unknown
What specific issues are you noticing? (Select all that apply)
*
How long has the plant been experiencing these problem(s)?
*
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Are the symptoms effecting all the leaves or just certain ones?
*
All leaves
Older leaves only
New leaves only
Unknown
Do the roots look healthy? (Only If you’ve checked)
*
I have checked but health unknown
Roots look healthy (white and firm)
Roots look unhealthy (brown, smelly, and mushy)
I haven’t checked
Where is the plant located? (Select all that apply)
*
what kind of light does the plant receive?
*
Direct sunlight
Bright, indirect
Low light
Unsure
Is the plant near any cold drafts?
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No, it is not near any drafts
Yes, its near a drafty window or door
Is the plant within a few feet of any air vents?
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Yes
No
Is the plant near any heat sources?
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Yes, near a heater,radiator, stove, fireplace, etc.
No
What’s the room temperature? (Select all that apply)
*
Do you use a humidifier?
*
Yes
No
Do you monitor the humidity?
*
Yes, it averages below 30%
Yes, it averages between 30-50%
Yes, it averages between 50-70%
Yes, it averages above 70%
No, I do not monitor
Do you check if the soil is dry before watering?
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Yes, by touch
Yes, using a moisture meter
No, I water on a schedule
No, I water by the way the plant looks
How often do you water the plant?
*
More than once a week
Once a week
Biweekly
Every 2-3 weeks
Once a month
Every 6 weeks
As I feel is needed
Randomly
How much water do you give it each time?
*
A few ice cubes
Just enough to moisten the topsoil
Until water runs out of the drainage holes
I’m not sure/ Random amounts
When was the last time the plant was fertilized?
*
Within the last week
Within the last month
Within the last 2-3 months
More than 4 months ago
Unknown
Do you fertilize the plant regularly?
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Yes, every 1–2 weeks
Yes, once a month
Yes, every 6 weeks
Yes, occasionally (less than every 6 weeks)
Yes, randomly
No, I don’t fertilize
Have you cleaned your plant leaves in the last 4-6 weeks?
*
Yes, with a leaf cleaner
Yes, with water
Yes, with a dry cloth
I have not clean the leaves
Have you made any changes to the plant’s environment recently?
*
What are your goals for this plant? (Select all that apply)
*
Anything else we should know?
