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YOUR PERSONAL SKIN ADVISOR

Use this Skin Advisor Form to receive your FREE customized skin prescription.


YOUR DETAILS

First Name:
*		 Last Name:
*		 Email Address:
*		 What's your age:
*


HEALTH BACKGROUND

Are you taking any medication? Yes No

Do you suffer from allergies? Yes No

Do you have mercury fillings? Yes No


SKIN DAILY ROUTINE AND TREATMENT PROFILE

Do you clean your skin with water? Yes No

Please, list all of the products you currently use on your skin (including make up):


Have your ever used any retinoids (Vitamin A derivatives)? Yes No

Have you ever used any alpha hydroxy and/or beta hydroxy products? Yes No

Have you ever used Benzyl Peroxide? Yes No


PH/ACID MANTLE PROFILE

Choose your skin type: Normal Dry Combination Oily

Do you ever experience flakiness? Yes No

Does your skin feel tight? Yes No

Does your skin shine during the day? Yes No Occasionally

Please, indicate the size of the pores: Large Fine

Do you ever breakout? Yes No

If yes, Do you breakout Frequently Occasionally Never

Where do you breakout? (Check all that apply)
Face Chest Back Other

Type of breakouts (mark all that apply):
Blackheads Small whiteheads (miliums) Large whiteheads Papules Pustules Cysts

Do you suffer from keloid scars or poor/slow scarring? Yes No

Do you shower/bathe with soap? Yes No


SENSITIVITY PROFILE

Is your skin sensitive to pressure? Yes No

Do you bleed/bruise easily? Yes No

Do you blush easily? Yes No

Does your skin tend to get easily irritated? Yes No

Do you suffer from telangiectasias/couperose (spider veins)? Yes No

Do you suffer from Rosacea? Yes No

Do you suffer from Psoriasis or Dermatitis? Yes No


PIGMENTATION/SUN TOLERANCE PROFILE

Do you have hyperigmentation (dark spots)? Yes No

Do you suffer from dark under-eye circles/eye puffiness? Yes No

Are you currently using hydroquinone (or have you ever used it)? Yes No

Have you been diagnosed with Vitiligo? Yes No

Do you sunbathe? Yes No

Do you sunscreen daily? Yes No

Does your skin burn easily? Yes No

Is your skin photosensitive? Yes No

Do you go to a tanning salon? Yes No

Do you expose yourself to television, computer and/or artificial light radiation for prolonged periods of time? Yes No


AGING PROFILE

Do you suffer from premature aging? Yes No

Are there any fine lines/wrinkles on your skin? Yes No

If you pinch your skin, does it snap back in place? Yes No

Do you have a double chin? Yes No


LIFESTYLE BACKGROUND

Is your stress level high? Yes No

Do you suffer from poor quality of sleep? Yes No

Do you smoke? Yes No

Do you drink at least 8 glasses of water daily? Yes No

Is your daily alcohol intake above 1 glass per day? Yes No

Do you drink more than caffeine 2 cups of caffeinated drinks per day? Yes No

Are you overindulging in any of the following: processed foods, refined sugar, dairy, artificial fats? Yes No

Do you exercise? Yes No


ELEVEN ELEVEN WELLNESS Rx

“Unhealthy skin or skin problems rather are usually an outer manifestation of an internal problem or imbalance, a symptom of an underlying imbalance. Removing the foods that trigger inflammation (a common cause of skin irritations) or doing a detox is a great way to clear up the skin. After that, giving the nutrients that people are usually lacking helps maintain good skin.”
Dr. Frank Lipman

Eleven Eleven Wellness is a leading-edge integrative health solution designed by Dr. Frank Lipman that will boost your entire system. Consisting of three programs - Remove, Revive and Sustain - it provides a cellular wake-up call that will make you look and feel great.

Taking advantage of your body’s natural ability to heal itself, each program includes the product kits, dietary and shopping guidelines, delicious recipes and a few simple but powerful exercises for all-round support on the program. Eleven Eleven Wellness is the best complement to your Sophyto Organics skincare routine; it is beauty from the inside out.

To get your Eleven Eleven Wellness Rx and start potentiating your topical skin regime, please select your greatest skin issue/concern (1 option) from the menu below:

Periorbital Dark Circles
Periorbital Puffiness
Hyperpigmentations
Premature Aging/Mature Skin
Skin Sensitivity/Allergies
Telangiectasias/Couperose
Rosacea
Psoriasis/Dermatitis
Impure/Acne-Prone Skin
Varicose Veins
Adiposis Edematosa (cellulite)
Stretch Marks
Healthy Skin (no skin issues/concerns)


Please enter the code to continue.





DISCLAIMER
No responsibility is taken for the misuse in any way of information provided herein. The FDA has not evaluated any statement made herein. None of the information provided is meant to act as a prescription, or medical advice. No SOPHYTO product is intended to diagnose, treat, cure, or, prevent any disease or illness. No liability is taken by SOPHYTO, or its employees, or, subsidiaries, for any claims arising out of the misuse, or otherwise, of any SOPHYTO product.