Online Colonoscopy Screening Fill out the form below and hit “Send” to submit your information to Great Lakes Surgical. A member of our team will be in touch within 48 hours (two business days) to discuss your answers and schedule a follow up appointment if necessary. Colonoscopy Screening Risk FactorsDo you have a personal history of polyps/cancer? Yes No Relationship Please note your conditionDo you have a family history of polyps/cancer? Yes No Relationship Please note the relationship and conditionDo you smoke? Yes No Quit Smoker How much do you smoke, and how long have you smoked? (i.e., "Pack/day, 1 year")Smoker - Quit How long have you been quit?Are you diabetic? Yes No Are you on insulin? Yes No Breathing Problems? COPD Asthma Inhaler use None Sleep disturbances? Snoring Sleep Apnea Have a CPAP machine None Cardiac problems? Heath attack Angina Hypertension Stents Bypass Pacemaker MVP Heart murmur Heart surgery Defibrillator Heart valve replacement None Are you under the care of a cardiologist? Yes No Have you had any joint replacements? Yes No Joint replacement Please list any/all replacementsPersonal DetailsHeight Weight BMI AgeContact InformationDue to the nature of medical information, you will be contacted by phone. Please make sure you provide an accurate phone number. Name First Last PhoneEmail How did you hear about our office? Internet search Social media Family/friend WLVL/Radio Union Sun & Journal Health magazine The Bee (Amherst Bee, Kenmore Bee, etc.) Other (please specify) Other General Info Call our office: 716-434-6141 GreatLakesSurgery@Yahoo.com 160 East Ave., Lockport, NY 14094 2914 Elmwood Ave., Kenmore, NY 14217 Better Health Care is Our Mission Same Day Appointments are Available. Phone: 716-434-6141 Fax: 716-434-0594 Email: GreatLakesSurgery@Yahoo.com Lockport Address: 160 East Ave. Lockport, NY 14094 Find us on Google Kenmore Address: 2914 Elmwood Ave. Kenmore, NY 14217 Find us on Google Appointments in Kenmore Office available by request Book an Appointment Today!