FORM 5
[ ] Check box if no longer subject to Section 16. Form 4 or Form 5 obligations
may continue. SEE Instruction 1(b).
[ ] Form 3 Holdings Reported
[ ] Form 4 Transactions Reported
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934, Section
17(a) of the Public Utility Holding Company Act of 1935 or Section 30(f) of the
Investment Company Act of 1940
1. Name and Address of Reporting Person*
Roberts Merle
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(Last) (First) (Middle)
2609 S. Everglade Street
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(Street)
Santa Ana, CA 92704
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(City) (State) (Zip)
2. Issuer Name and Ticker or Trading Symbol
Dental/Medical Diagnostic Systems, Inc. (Nasdaq - Common
Stock: "DMDS" and Warrants: "DMDSW")
3. IRS or Social Security Number of Reporting Person (Voluntary)
4. Statement for Month/Year
February 1999
5. If Amendment, Date of Original (Month/Year)
02/99
6. Relationship of Reporting Person to Issuer
(Check all applicable)
Director 10% Owner
--- ---
X Officer (give Other (specify
--- title below) --- below)
Vice-President of Manufacturing
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7. Individual or Joint/Group Filing (Check applicable line)
X Form Filed by one Reporting Person
---
Form Filed by more than one Reporting Person
---
TABLE I -- NON-DERIVATIVE SECURITIES ACQUIRED,
DISPOSED OF, OR BENEFICIALLY OWNED
<TABLE>
<CAPTION>
1. Title of Security (Instr. 3) 2. Trans- 3. Trans- 4. Securities Acquired (A) or 5. Amount of 6. Ownership 7. Nature of
action action Disposed of (D) Securities Form; Indirect
Date Code (Instr. 3, 4 and 5) Beneficially Direct Beneficial
(Month/ (Instr. ---------------------- Owned at End (D) or Ownership
Day/ 8) Amount (A) or Price of Issuer's Indirect (Instr. 4)
Year) (D) Fiscal Year (I)
(Instr. 3 (Instr. 4)
and 4)
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<S> <C> <C> <C> <C> <C> <C> <C> <C>
Common Stock 7/27/98 P 1,300 A 4.125 11,300 D
</TABLE>
If the form is filed by more than one Reporting Person, see Instruction 4(b)(v).
Reminder: Report on a separate line for each class of securities beneficially
owned directly or indirectly.
(Print or Type Responses) (Over)
<PAGE>
FORM 5 (CONTINUED)
TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
<TABLE>
<CAPTION>
1.Title 2.Conver- 3.Trans- 4.Trans- 5.No. of 6.Date Exer- 7.Title and 8.Price 9.Number 10.Owner- 11.Nature
of Deri- sion or action action Deri- cisable Amount of of of Deriv- ship of of In-
vative Exercise Date Code vative and Expi- Underlying Deri- ative Deriva- direct
Security Price of (Month/ (Instr. Securi- ration Securities vative Securities tive Bene-
(Instr. 3) Deri- Day/ 8) ties Ac- Date (Month/ (Instr. 3 Security Bene- Security; ficial
vative Year) quired Day/Year) and 4) (Instr. 5) ficially Direct (D) Owner-
Security (A) or Owned at or Indi- ship
Disposed End of rect (I) (Instr.
of (D) Year (Instr. 4) 4)
(Instr. 3, (Instr. 4)
4, and 5)
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(A) (D) Date Expira- Amt. or
Exer- tion Title No. of
cis- Date Shares
able
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<S> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C> <C>
Options $4.00 10/9/98 A 20,000 * 10/9/08 Common 20,000 $0 62,066 D
Stock
Warrants 5.00 7/6/98 P 10,000 Common 10,000 1.75 30,000 D
Stock
Warrants 5.00 7/27/98 P 10,000 Common 10,000 1.625 30,000 D
Stock
</TABLE>
Explanation of Responses:
* Options shall vest and become exercisable 20% per year over a period of five
(5) years.
"
**Intentional misstatements or omissions of facts constitute Federal
Criminal Violations.
SEE 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
NOTE. File three copies of this Form, one of which must be manually
signed. If space provided is insufficient, SEE Instruction 6 for procedure.
/S/ MERLE W. ROBERTS 4/20/99
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**Signature of Reporting Person Date
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