Bedrest Activity Checklist
Use this chart to work with your physician on the appropriate level of activity for each stage of your pregnancy:
Overall Activity
____Normal
____Slight decrease
____Significant decrease
____Complete bedrest
Driving
____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
Leisure
____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 ___________________