Psoriasis-Ltd IV Assistance Form

The purpose of the Psoriasis-Ltd IV Assistance Form for existing Psoriasis-Ltd IV patients only:

To assist you in improving the appearance and condition of your Psoriasis, acne or seborrheic-dermatitis skin condition, please complete all blanks below. Optional information (up to a full page of your comments) is welcome in the comment section.

Please be precise so we can assist you. We need to know what you have been doing, and what you have "NOT" been doing'. You are not limited to the boxes below as they will continue for several paragraphs if needed.


File date or "Date on your Letter of Instruction.
Please use this format ##/##/####

Email address:

1. How many years do you think that you have had Psoriasis?

2. How many years have you seen a dermatologist for Psoriasis?

3. What medication have you most recently used "just prior" to using Psoriasis-Ltd IV? And which other in the past?

On a scale of 1 to 10 please rate the appearance of existing Psoriasis affected skin area after the use of Psoriasis-Ltd IV:

 0  1  2  3  4  5  6  7  8  9 10
4. Are your affected areas less noticeable?
5. Is any inflammation less visible?
6. Do you see less surface area of reddish flaky skin color?
7. Do you feel less intensity of redness and flakiness since you began?

Also, please include your answers to the following so we may assist you further. To read our recommendations, please click on the links.

8. The number of glasses of "alkaline water" you are drinking each day? Alkaline water has a pH between 7.0 and 7.3. Please review on our
Psoriasis's Cause and Cure page.

9. The soap you are using to clean your face and if the brand offers more than one soap, give us the exact one so we can confirm that you are using the proper one.

10. Are you using the Jojoba oil or Safflower oil as recommended?
Yes No

11. Please answer each individual question as follows. How many cups of the following do you drink?
Soft Drinks:

12. Any other thoughts or unusual considerations that you would like to tell us or ask us.

Please type in the numbers below:


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