Form 190 - Quantitative Liver Function Test Record Page 3
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4Patient ID:
___ ___ - ___ ___ ___ - ___
CAFFEINE & ANTIPYRINE
Procedure Description Projected
a. Projected Date
b. Projected
d. Actual Date
e. Actual Time
T-Time
MM/DD/YYYY
Time
MM/DD/YYYY
HH:MM
HH:MM
__ __ : __ __
__ __ : __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
Caff &
1 x 2ml
T = 6 hrs
E20.
c . A M……1
f . A M……1
AP
saliva
P M……2
P M……2
__ __ : __ __
__ __ : __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
Caff &
1 x 2ml
T = 12
E21.
c . A M……1
f . A M……1
AP
saliva
hrs
P M……2
P M……2
__ __ : __ __
__ __ : __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
Caff &
1 x 2ml
T = 24
E22.
c . A M……1
f . A M……1
AP
saliva
hrs
P M……2
P M……2
__ __ : __ __
__ __ : __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
Caff &
1 x 2ml
T = 36
E23.
c . A M……1
f . A M……1
AP
saliva
hrs
P M……2
P M……2
__ __ : __ __
__ __ : __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
Caff &
1 x 2ml
T = 48
E24.
c . A M……1
f . A M……1
AP
saliva
hrs
P M……2
P M……2
__ __ : __ __
__ __ : __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
Caff &
1 x 2ml
T = 60
E25.
c . A M……1
f . A M……1
AP
saliva
hrs
P M……2
P M……2
SECTION F: BATCH AND LOT NUMBERS
Indicate the pharmacy lot number and/or batch number for each compound.
Compound Name
Pharmacy Lot and/or Batch Number
F1.
Compound B: Galactose
F2.
Compound C: IV Cholate
F3.
Oral Compound
HALT-C Trial
QLFT AS
Form # 190
Version B: 07/06/2001
Page 3 of 4
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