FICHA MUSICOTERÁPICA

Fortaleza, _____de ______________de________.

Indicação:_________________________________________________________

DADOS PESSOAIS
Nome:___________________________________________________________
Data do nascimento __________ / _____________ /__________
Idade:_________ Sexo (F) (M) Religião:_______________________
Nacionalidade:_________________________ Naturalidade:______________________
Escolaridade:__________________
Endereço: ________________________________________________________________
CEP:______________ E-mail:_________________________________________
Fones: Res.( )_____________ _____ Cel.(___)_______________________
Responsável pelo tratamento:____________________________________________________

DADOS FAMILIARES
Pai:___________________________________________ Idade:_________________
Profissão:_______________________
Mãe:__________________________________________ Idade:_________________
Profissão:_______________________

CONSTELAÇÃO FAMILIAR
Nome:________________________________________ Idade:__________________
Escolaridade:__________________________________
Nome:________________________________________ Idade:__________________
Escolaridade:__________________________________
Nome:________________________________________ Idade:__________________
Escolaridade:__________________________________

DADOS CLÍNICOS
1. HISTÓRICO
1.1 Condições da gestação:
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1.2 Condições do parto:

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1.3 Doenças infantis:

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1.4 Dados diagnósticos:

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1.5 Antecedentes psicopatológicos:

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1.6 Medicação atual:

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1.7 Alergias:
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1.8 Crises convulsivas:
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1.9 Desenvolvimento Neuropsicomotor:

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DESENVOLVIMENTO SOCIAL

1. Cuidados pessoais:
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2. Grau de dependência:
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3. Características pessoais (personalidade):

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4. Raciocínio:
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5. Comunicação:
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6. Situação escolar:
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7. Observações:
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DADOS MUSICAIS

Dados fornecidos por:___________________ ______ Grau de parentesco:__________

1. Costuma ouvir música? (S) (N).
2. Com qual frequência? (Muita) (Pouca).
3. Como costuma ouvir música? (Rádio) (MP3) (TV) (Cd) (DVD) (Outros).
4. Quando ouve música: (Fica atento) (Faz outras coisas) (Se isola) (Outros).
5. Já obteve algum aprendizado musical? (S) (N).
6. Costuma participar de festas? (S) (N).
7. Já assistiu apresentações musicais? (S) (N).
8. Já tocou algum instrumento musical? (S) (N). Qual(ais)? ___________________________
9. Que tipo de música gosta de ouvir? (Vocal) (Instrumental).
10. Que tipo de música prefere? (Erudita)(Estrangeira)(MPB)(Religiosa)(Folclórica)(Outros).

11. Quais os cantores que prefere?

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12. Quais os cantores que não gosta?
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13. Quais os instrumentos musicais que lhe agradam?

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14. Quais os instrumentos musicais que lhe

desagradam?__________________________________________________________________
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15. Quais os ruídos ou sons que lhe agradam?

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16. Quais os ruídos ou sons que lhe desagradam?

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17. Quais as canções infantis que gosta?

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18. Quais as canções infantis que não gosta?

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19. Quais as brincadeiras infantis que mais gosta?

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20. Quais as brincadeiras infantis que não gosta?

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21. Cite músicas prediletas:

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22. Cite músicas que desagradam:

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23. Observações:
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