Bedrest Activity Checklist

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Use this chart to work with your physician on the appropriate level of activity for each stage of your pregnancy:

Overall Activity

____Slight decrease
____Significant decrease
____Complete bedrest


____Drive as normal
____Drive only as needed
____Passenger only
____Ride only to appointments

Employment (Physician should know what your job entails: physical requirements like how much time you spend standing, stress level, details of your commute, etc.)

____Work full-time as usual
____Work part-time for only _______ hours
____Work from home for only ______ hours

In what position:

____ chair ____ recliner ____ lying on side
____Other ___________________________
____Stop working completely

Child Care

____Care for children as usual
____No breastfeeding
____No carrying children
____No lifting children
____No bending or stooping
____Need childcare provider


____Normal activities
____Stop intense activities like jogging, climbing, etc.
____Short walks only
____Sit at desk/table only
____Recline: watch TV, talk on phone, read
____Activities lying down only

General Mobility (Physician should know if you live in a multi-story house or walk up several flights of stairs to your apartment.)

____Normal mobility
____Limited (sitting mostly)
____Lie down ____ hours per day
____May go up/down stairs ___ times
____Light walking only
____Sit to eat only
____Recline all day
____Lie flat all day (on left or right side?)
____Use wheelchair

Bathroom Privileges

____Normal bathroom privileges
____Avoid constipation
____Must use bedside toilet
____Must use bedpan
____Short showers only
____Shower sitting down only (using shower chair)
____Reclined bath only
____Bedside sponge bath only
____Other ________________

Sexual Relations

____Normal relations
____Occasional relations only
____Avoid intercourse
____Avoid female stimulation/orgasm
____No sexual relations

Household Activities

____Heavy: laundry, vacuum, change bed sheets
____Prepare meals, wash dishes (standing)
____Light: dusting, straighten beds
____Grocery shopping
____Other ___________________