Substances and Choices Scale

Download SACS questionnaire to complete manually here (use the Community Questionnaire) and fill in this e-version later)
Date of assessment:

Patient Details

From:
Patient Name:  
Date of Birth:
NHI:
Home address:
Postal address:
Home phone:
Work phone:
Mobile phone:

The following questions are about your (young person's) use of alcohol and drugs over the last month. This does not include tobacco or prescribed medicine. Please answer every question as best you can, even if you are not certain.

SACS Part A:

How often did you use each of the following in the last month? Didn't use Once a week or less More than once a week Most days or more
Alcoholic drinks (e.g. beer, wine, spirits, premixes, RTDs):
Cannabis (e.g. weed, marijuana, pot, dope, buds):
Other drugs (e.g. stimulants, hallucinogens, inhalants, sedatives, synthetic cannabinoids, opiates):









SACS Part B:

Mark one box (on each row), on the basis of how things have been for you over the last month? Not True Somewhat True Certainly True
1. I took alcohol or drugs when I was alone.
2. I've thought I might be hooked or addicted to alcohol or drugs.
3. Most of my free time has been spent getting hold of, taking, or recovering from alcohol or drugs.
4. I've wanted to cut down on the amount of alcohol and drugs that I am using.
5. My alcohol and drug use has stopped me getting important things done.
6. My alcohol or drug use has led to arguments with the people I live with (family, flatmates or caregivers etc.).
7. I've had unsafe sex or an unwanted sexual experience when taking alcohol or drugs.
8. My performance or attendance at school (or at work) has been affected by my alcohol or drug use.
9. I did things that could have got me into serious trouble (stealing, vandalism, violence etc) when using alcohol or drugs.
10. I've driven a car while under the influence of alcohol or drugs (or have been driven by someone under the influence).

Alcohol Consumption Screen:

Patient is: Within Adult Guideline Above Adult Guideline
  • No more than 15 10 standard drinks per week.
  • At least two alcohol-free days per week.
  • Is not binge drinking (6 (5 or more on one occasion).
  

Notes:


Low Risk

  • Provide positive feedback about healthy choices
  • Monitor for AOD concerns in the future
No significant problems identified.

Low Risk

  • Provide positive feedback about healthy choices
  • Monitor for AOD concerns in the future

Level of AOD problems could be significant and require further assessment and/or treatment.

  • Consider HEADDS assessment to get more information.
  • Provide brief advice
  • Discuss possible referral to AOD services with client.

Moderate Risk

Level of AOD problems could be significant and require further assessment. Consider referral.

  • Gather more information. Consider HEEADDSSS assessment.
  • Provide brief advice and pocket card resource.
  • Discuss possible referral to AOD service.

Level of AOD problems are significant and require further assessment and treatment.

  • Recommend referral to AOD services if client willing.
  • Provide brief advice to support referral.

High Risk

Level of AOD problems is significant and requires further assessment and treatment.

  • Gather more information. Consider HEEADDSSS assessment.
  • Provide brief advice and pocket card resource.
  • Recommend referral to AOD service.

Level of AOD problems are serious and require further assessment and treatment.

  • Strongly recommend referral to AOD services if client willing.
  • Provide advice to support referral.

For youth AOD services in your area click here.

Please consider confidentiality when making a referral.

Please consider family when making a referral.

Referral to AOD service discussed and recommended
Has the young person agreed to this referral?
(Agreement is required)
Are the parents of the young person aware of this referral?
(To allow discretion with contacting the young person)

Form will be saved to the patient's "Forms" in a format suitable for printing and faxing to the DHB.

Form will be saved to the patient's outbox in a format suitable for sending to the DHB.

Form will be saved as an attachment to the consult note in a format suitable for printing and faxing to the DHB.


We need feedback from primary care providers about this electronic version of the SACS. It will only take 3 minutes. Please provide feedback here once you are familiar with the SACS (have used it a few times).

SACS content © Health Promotion Agency (hpa.org.nz).
This implementation © Procon Limited 2015