Form 190 - Quantitative Liver Function Test Record Page 2
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4Patient ID:
___ ___ - ___ ___ ___ - ___
20mg 13C-Cholate
Administer IV
in 5mls 25%
D7.
T = 9-10 min
____ ____ min
____ ____ : ____ ____
compound C
Albumin (10mls
total)
SECTION E: SPECIMEN COLLECTION TIMES
CHOLATE, MEGX, & GALACTOSE
Procedure
Description
Projected
a. Actual Timer
b. Actual 24hr Clock
T-Time
T-Time
Time ( HH:MM )
5min
E1.
1 x 5ml red top
T = 15 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
15min
E2.
1 x 5ml red top
T = 17 min
___ ___ ___ min
____ ____ : ____ ____
MEGX
10min
E3.
1 x 5ml red top
T = 20 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
15min
E4.
1 x 5ml red top
T = 25 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
20min
E5.
1 x 5ml gray top
T = 28 min
___ ___ ___ min
____ ____ : ____ ____
Galactose
20min
E6.
1 x 5ml red top
T = 30 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
30min
E7.
1 x 5ml red top
T = 32 min
___ ___ ___ min
____ ____ : ____ ____
MEGX
30min
E8.
1 x 5ml red top
T = 40 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
40min
E9.
1 x 5ml gray top
T = 48 min
___ ___ ___ min
____ ____ : ____ ____
Galactose
45min
E10.
1 x 5ml red top
T = 55 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
60min
E11
1 x 5ml gray top
T = 68 min
___ ___ ___ min
____ ____ : ____ ____
Galactose
60min
E12.
1 x 5ml red top
T = 70 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
75min
E13.
1 x 5ml red top
T = 85 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
80min
E14.
1 x 5ml gray top
T = 88 min
___ ___ ___ min
____ ____ : ____ ____
Galactose
90min
E15.
1 x 5ml red top
T = 100 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
105min
E16.
1 x 5ml red top
T = 115 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
120min
E17.
1 x 5ml red top
T = 130 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
150min
E18.
1 x 5ml red top
T = 160 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
180min
E19.
1 x 5ml red top
T = 190 min
___ ___ ___ min
____ ____ : ____ ____
Cholate
HALT-C Trial
QLFT AS
Form # 190
Version B: 07/06/2001
Page 2 of 4
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